COMMENTARY Nov 2014. Christian Journal for Global Health, 1(2):7-15. Framing the Role of the Faith Community in Global Health Mark A. Strand a and Andrew M. Cole b a PhD, Associate Professor, Pharmacy Practice, Master of Public Health Program, College of Pharmacy, Nursing and Allied Sciences, North Dakota State University, USA b MBBS, FAFRM, Conjoint Associate Professor, School of Public Health and Community Medicine, University of New South Wales, Australia Abstract Globalization has brought many people and organizations together. Healthcare is one of the fields that has been the most prominent in global collabora- tion. Healthcare professionals working from the framework of Christian faith have been participants and leaders in global health for many years. The current chal- lenges in global health call for the active involvement of all concerned players, Christian healthcare professionals among them. In this paper, the authors suggest a unique framework for Christians involved in global health to make contributions to research, scholarship, and practice innovation in this field. Introduction The inauguration of the Christian Journal for Global Health is welcomed by people around the world who share a commitment to global health and the unique role that people of Chris- tian faith play in it. While the focus of the jour- nal might seem implicit, in fact, the launching of this journal creates the opportunity for new para- digms to be explored. The purpose of this article is to propose a way of framing the role of Christians in global health, and thereby invite others to work within and expand that framework. The approach of the paper is to define each of the terms, global, health and Christian, and then propose a way in which the intersection of the three concepts may be understood. It is the authors’ contention that there is something distinctive about this intersec- tion and that there is a paucity of current litera- ture specifically describing the intersection. Background In order for Christians involved in global health to have impact that is distinctively Chris- tian and results in improved health for people around the world, it is important that careful con- sideration be given to how this might happen. ―Christian‖ is here taken to mean centered on Jesus Christ and faithful to the Bible. Since early church times, Christians have provided extensive health services at times when these did not exist on a public scale. 1 Both before and after the Reformation, Catholics and Protestants were deeply engaged in the establishment of healthcare and healing ministries across cultural and politi- cal boundaries. 2-4 And it can be argued that mod- ern medicine was introduced to many regions of the world through the efforts of medical mission- aries in the 19 th and 20 th centuries. 5 This rich tra- dition provides extensive resources from which to glean perspectives and models that might inform 8 Strand and Cole Nov 2014. Christian Journal for Global Health, 1(2):7-15. current Christian contributions in global health and could still be of relevance today. Today’s global health stage is crowded with players, Christians being only one group among many. 6 Some, but not all, of the concerns of distinctively Christian organizations and those working from a secular or another faith-based perspective may be held in common. There has been an increase in the number and influence of humanitarian global health organizations in re- cent decades relative to faith-based organizations. Consequently, as the relative contribution of Christians in global health has become less, it is imperative that Christians expend additional ef- fort to describe better their role and contributions in global health, in a way that is clear and win- some to people who may or may not share their Christian faith. Proposed Framework The following framework for understand- ing a distinctive ―Christian global health‖ identity and role has been constructed by the authors through selective review of the literature and ex- tensive discussion, developing the three dimen- sions of Christian global health. Global In the third millennium of the Christian era, the world has changed to become a more con- nected community. Western nations alone are not able to direct global affairs through their se- lective influence or expect passive responses from other nations. The economic and techno- logical rise of nations such as China and India is beyond dispute. New global alliances among emerging markets, such as the group of BRICS nations (Brazil, Russia, India, China, and South Africa) challenge the assumption of unbroken Western dominance. In healthcare, it has become even more difficult to identify which countries are sending medical assistance and which receive it. By 2009, China had helped build 30 hospitals and provided $143.9 million USD in foreign aid to help African governments treat malaria. 7, 8 Therefore, any claim to be global must take seri- ously this reconfigured contextual reality. This currently complex age calls for care- fully considered strategies and innovative leader- ship. Medical missions now function in and de- liver care through a multiplicity of agencies oper- ating in international health — including NGOs, government agencies and multilateral organiza- tions — which has resulted in a perceived loss of the unique presence of Christian medical mis- sions in some settings. 9 It is time to create new strategies and ap- proaches by which Christian medical missions operations can establish even greater legitimacy and effectiveness. 10 This does not necessarily require multimillion-dollar investments or pro- jects, but rather requires well-trained, well-placed individuals working together in highly effective teams for sufficiently long periods of time. It also includes partnership with the local church as appropriate. The healing mission of the church is expressed both through Christian healthcare or- ganisations and the ministry of the local church to its community, as the communities of the world determine their political and cultural context for themselves. In any given setting, a global health per- spective is first informed by local health and faith movements, and then requires analyses of healthcare needs from within the local context and culture, finally being informed by models that have proven effective in other locations. Clearly, this brings greater opportunity for global partners to speak for themselves and for their voice to be heard. 11, 12 Global health focuses on shared challenges and problems, to which both rich and poor countries alike are vulnerable. These are best addressed by bringing global part- ners together to discuss solutions in settings of cooperative equality and mutual respect. 13 Western nations have rapidly undergone an epidemiologic transition so they are now experi- encing high rates of ageing and chronic diseases, such as diabetes and mental health disorders. 9 Strand and Cole Nov 2014. Christian Journal for Global Health, 1(2):7-15. Most regions of the world are at various stages of experiencing a similar transition, including sub- Saharan Africa. 14, 15 Transitioning a healthcare system from an acute to a chronic care model is challenging, but lessons learned in one place can be shared with another country. 16 Conversely, middle income countries with highly organized healthcare systems, such as China and Cuba, have had success with community-based chronic dis- ease management models and have much to offer other countries. 17, 18 The local response to HIV- AIDS in Africa has also informed both local healthcare delivery and national healthcare sys- tems. A truly global perspective assumes that each country has something important to learn from every other country. 19 This global approach assumes the concept of ―sphere sovereignty,‖ first comprehensively formulated by the theologian and Netherlands prime minister Abraham Kuyper. 20 Sphere sov- ereignty posits that each area of life or societal community has its own sovereign authority, which must be objectively appraised in its own space, and no one sphere is sovereign over anoth- er, except for God’s sovereignty which is over all. Therefore, critique of a given country or method must begin with an objective appraisal of that country or method in its own context, with secondary critique from an external perspective then being dependent on the antecedent objective and local understanding. The framework for global perspective be- ing proposed is best built by the work of re- searchers and practitioners who are living long- term in the countries about which they write, whether as nationals or expatriates who have be- come culturally immersed in those countries. This assumes that one has first taken seriously what anthropologists call the emic (insider) per- spective, with writing that reflects the full reality of someone who tries to understand complexity from an inside perspective. Further, this approach should strive to avoid political or religious bias and must be fac- tual and evidence-based. Any bias that might influence the direction of analyses must be de- clared. The work should respectfully represent the corner of the globe to which it speaks. The global friends about whom the publication speaks should be aware of what is being written and par- ticipate in providing context and explanatory power. Health Health has been defined by the World Health Organization as ―a state of complete phys- ical, mental, and social well-being and not merely the absence of disease or infirmity.‖ 21 While not specifying spiritual health, this defini- tion has space for Christian concepts of whole health to be included. Many Christian organiza- tions, including the World Council of Churches, have defined health in a way that incorporates the essentiality of the spiritual dimension of health. At the same time, it is important that evi- dence-based approaches are relied upon to sub- stantiate any claims to efficacy of modern healthcare methods, the evidence having been generated by research and application. This pro- posed framework, therefore, assumes the use of a scientific approach to the evaluation of evidence, both qualitative and quantitative. In the pursuit of a global health perspec- tive, evidence must be followed wherever it leads. 22 For example, the discovery of Helico- bacter as the agent responsible for gastric ulcers and the Chinese herbal medicine Qinghaosu (ar- temisinin) as an effective therapy for treating ma- laria, both required standing against intellectual inertia and prevailing wisdom. The possibility of medical breakthroughs may be uniquely open to those who are prepared to cross cultures and ap- preciate the special evidence then available to them. In order to increase the scholarly produc- tivity of research partners in low and middle in- come countries, it will be necessary to invest more time, personnel, and resources in strength- ening their research capacity. 23 This will require 10 Strand and Cole Nov 2014. Christian Journal for Global Health, 1(2):7-15. more training in research methods and providing opportunities and resources to these global col- leagues to help them engage in research. The highest standards for ethical research must be employed. Global research has past egregious examples of unethical treatment of re- search subjects, 24, 25 so the approval of institu- tional review boards must be sought in all re- search situations. If such boards do not exist in a country, they should be created for the desired purpose of providing ethical oversight of high quality research and ethical care there, with local- ly appropriate informed consent from participants for any use of personal data. 26 Healthcare services are expected to provide the most cost-effective care to the greatest num- ber of people, with the subjects of research being the first to benefit from whatever is discovered as a result of their participation. Therefore re- searchers and scholars will declare and avoid conflicts of interest with pharmaceutical compa- nies, software designers or other financial inter- ests that are driven by profit or control or that might compromise their commitment to bring the greatest benefit to those who need it most. Christian Just as healthcare information must be evi- dence-based, and one’s global perspective must be fair and impartial, so Christian faith must ad- here to historically and theologically sound crite- ria. As initially noted, for ―Christian global health‖ to be truly Christian, it must center on Jesus Christ, be faithful to the Bible, and should reflect normative Christian practices and ethics. Additionally, the work of Christians should be based on widely accepted best practices, and presented in a way that is discernible and reason- able to people who do not share their Christian faith position, yet retaining theological integrity. A helpful concept here is that of ―middle level axioms,‖ as described by Reinhold Nie- buhr. 27 Middle level axioms are middle-ground words and concepts that are understood by multi- ple groups of people, even those who may not share the same theoretical perspective. For ex- ample, from a materialist perspective a principal focus in palliative or aged care may be control of the physical symptom of pain. But from a Chris- tian perspective, the hope of eternal life after death, living in God’s presence where there shall be no mourning, crying, or pain is also very real. Therefore, for Christians to describe research into the impact of the hope of eternal life after death, upon present pain, or coping with a painful ter- minal condition, would require the use of middle level axioms to describe ―the hope of eternal life,‖ in a way that a reader who adheres to a ma- terialist perspective would understand and could then value. This might mean balancing increasing use of pain medication with a person’s desire to be able to derive comfort from personal contempla- tion of future life. In this case, the middle level axiom is describing increased individual pain tol- erance in a terminal patient, in terms of greater ability to endure pain at the moment because of the promise or hope of a future life that goes on forever, perfectly, and without pain. Christians working in global health and having long-term residence in a foreign country have a unique opportunity to contribute with deep understanding of the history, language, and cul- ture of that country. Many medical missionaries themselves are what William Easterly would call searchers. 28 These are people who are on the ground, attentive to what is happening, encourag- ing local initiatives, and providing close account- ability. 29 Inasmuch as social transformation oc- curs at a community level, religious bodies are there, in the community, serving as a force for good, even if at times they might be perceived as being sectarian or isolationist. Religious communities frequently have high levels of credibility in their local communi- ty. Taylor-Ide and Taylor identify three main players in community change: government, pro- fessionals and the community. 30 Faith-based or- ganizations (FBOs) often function as an intimate 11 Strand and Cole Nov 2014. Christian Journal for Global Health, 1(2):7-15. participant at both the professional and communi- ty level, so they are in the ideal position to be catalysts for good work that is appropriate for that community, uniquely validating the work done by Christians involved in global health. Even secular agencies like UNAIDS have identi- fied the essential role of FBOs in delivering healthcare services to AIDS patients. 31 One feature of the Christian ethic is respect for the dignity of persons. This is shown both in the way in which one’s work is done and the way in which it is portrayed. For example, the use of images of patients or people in the community, or their medical information, should be done with individual permission and adhere to normal standards of information privacy protection. 32 The faith community thus has the oppor- tunity to impact the direction of global health in a way that more truly reflects the needs, concerns, and hopes of communities most in need around the world. One thinks of the impact of medical missionaries through their work in the Christian Medical Commission (CMC) that came about as a result of the Tubingen Consultations, estab- lished because of concerns over the operation of church health services. 33 The CMC ultimately gained the hearing of the World Health Organiza- tion, driving the establishment of the concept of primary health care for all, first made explicit with the Alma Ata Declaration in 1979. 34-36 This serves as a reminder that Christians can have an impact that extends well beyond their own faith community, and people who do not share their Christian faith can still embrace their work, be- cause it represents quality work and progressive ideas that uniquely address pressing needs. Research and Scholarship Gaps The three concepts of Christian, global, and health can be conceptualized by an inter- dependent relationship, as shown in Figure 1. We suggest that much scholarship has been done in each of the three disciplines individually, rep- resented by each individual circle. However, scholarly contributions from the areas of intersec- tion between any two circles, and the central re- gion where all three overlap, is far less frequent. Figure 1. A model for relating the concepts of Christian global health The desire is to develop innovation and scholarship at the interface of evidence-based healthcare practice and contextualized global per- spectives, with that interface being fully informed by Christian thinking. This clearly requires the engagement of healthcare professionals every- where with interest in global health issues, who also have an ability to analyze the interface from a uniquely Christian perspective. At the same time, the work should be in- spiring to people of faith and testify to the veraci- ty of their faith. 37 There are many ways that global health done by Christians can testify to the gospel, for example, by communicating and em- bodying the larger vision of human origin, nature and destiny. This involves upholding belief in the dignity of each person as created in God’s image, while at the same time acknowledging the brokenness of humanity and the consequences on human experience. People who don’t believe the Christian faith might not share this perspective, but Christians who illuminate these issues, and behave consistently, can set forth a clear and just vision for all to see and understand. Christian global health also impacts society in a normative way by establishing a whole range of social, legal, and political norms that reflect 12 Strand and Cole Nov 2014. Christian Journal for Global Health, 1(2):7-15. the values of the kingdom of God. The recent publication of Robert Woodbury’s work on the social impact of what he calls ―conversionary Protestant‖ Christian missionaries around the world has brought this to light in a convincing manner. 38 This process calls on Christians to build trusting relationships and to demonstrate honesty in one’s work in a way that is winsome and transparent. Finally, Christian global health testifies to the world in a truly holistic way by proclaiming the saving gospel of Jesus Christ to those in one’s sphere of influence. Secular readers do not share this view, but it is a testimony from which sincere Christians will not shrink. Table 1 presents a list of research areas and examples of research questions that lie within the intersection of the circles of healthcare and global need. While not exhaustive, this list represents areas where further research into a distinctively Christian approach may bring the intersection of the third Christian circle into clear focus. For instance, the first example in the table, ―Geriatric and restorative care in an ageing world,‖ could result in researching current clinical models in low and middle income countries, with a view to evaluating their preparedness for expanded num- bers of geriatric and chronic disease patients. Each of the examples in Table 1, and many others that are not listed, could likewise be developed. The process of conducting this work could unfold in many ways. For example, a group of concerned persons could come together for a col- laborative discussion, applying their expertise to identify existing knowledge gaps, which could then lead to identifying research needing to be done, for example in relation to developing prac- ticable models of care. Incremental research con- tributions would over time build a body of evi- dence that would be compelling. The contributions of Christian healthcare workers to improved global health have been consistently reported. 39-42 However, there is much more that could be done to explore and ex- plain the unique nature of medical care provided by Christians. As evidence is generated, analyses could be done to demonstrate the distinctive as- pects of the faith perspective that predict im- proved outcomes in patients. 43, 44 Furthermore, this process could increase documentation of im- portant work that has previously gone unrecord- ed. Table 1. Research areas to pursue and examples of gaps to be filled. Research Area Examples Special populations Geriatric and restorative care in an ageing world. Sustainable care for people with mental illness. End of life care in different contexts. Demonstrating the efficacy of cheaper drugs compared to more expensive new drugs. Health services planning, de- livery and evaluation Impact of providing free services or free medications. Models of chronic disease management and supportive care. Design of instruments to measure spiritual impact or outcomes. Evidence for the effectiveness of distinctively Christian global health initiatives. Framework for prioritizing disease interventions using criteria reflective of the Christian ethic. Healthcare leadership and workforce Understanding the global mental health services shortage. Mental health status and risk factors for cross-cultural medical professionals. Servant leadership approaches in healthcare. Professionalism in healthcare rooted in Christian ethical values. Social and behavioral sciences Human decision-making processes in the face of health crises. Social, psychological and spiritual factors in holistic healthcare. Causes and solutions to global human trafficking. Variable distribution and causes of diseases in different populations. 13 Strand and Cole Nov 2014. Christian Journal for Global Health, 1(2):7-15. 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Annu Rev Public Health. 2007;28:213–34. http://dx.doi.org/10.1146/annurev.publhealth.28.02140 6.144016 Peer Reviewed Competing Interests: None declared. Correspondence: Mark A Strand, PhD, College of Pharmacy, Nursing and Allied Sciences, North Dakota State Uni- versity, 118L Sudro Hall, Fargo, ND, 58101. Fax: 701-231-7606. Mark.Strand@ndsu.edu Cite this article as: Strand, MA and Andrew M Cole. Framing the Role of the Faith Community in Global Health. Christian Journal for Global Health (November 2014), 1(2):7-15. http://dx.doi.org/10.15566/cjgh.v1i2.19 © Strand, M.A. and A.M. Cole. This is an open-access article distributed under the terms of the Creative Com- mons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provid- ed the original author and source are properly cited. 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