Chapter 2: The Present

I. Today's Setting

The picture for medical missions should be quite rosy. Medical science has advanced powerfully in its battle against disease. Doctors and nurses do not have to stand by compassionately but helplessly as patients come to them with cholera, measles, asthma, tuberculosis, appendicitis or congestive heart failure.

Medical missionaries have not only received better training and become better equipped to handle the gamut of disease processes, but they have been teaching these skills and methods to nationals. The influence of medical missions on the treatment of illness and injuries in developing nations is enormous.

According to one study, in 1968 mission hospitals provided the following percentages of total medical services in these countries of the Two-Thirds World:

If one looked at only one nation to document the impact. of Christian medical missions, the best example would be India. Only 3% of India's millions are Christian, yet one-fifth of the hospital beds in the nation are provided in Christian medical institutions, and two-thirds of the trained nurses are graduates of Christian schools of nursing. (R. K. M. Sanders 1984A)

Truly, the history of medical missions is a fantastic story revealing much for which to be thankful. Yet, there are two major clouds hang mg over us which threaten the celebration. The first is that it is increasingly difficult to maintain existing mission hospitals and for them to pursue their original purposes. The second is that despite all the doing and the teaching of the past 130 years, there are more sick and poor people in the world than ever before. The health gap between the haves and the have nots is wide and getting wider all the time. The rest of this chapter will address these two problems.

II. Maintaining Existing Mission Medical Centers

A. Finances

Many mission hospitals were originally established in remote rural areas in order to serve the poor. As the budgets have increased, missions have sought ways to make these hospitals self-supporting. This usually has included setting up a fee-for-service billing structure aimed at generating sufficient funds to meet the staff payroll and the costs of drugs and supplies.

Unfortunately, the end result of this sequence of events is that the poor, who can ill afford the time or the money for trips to the hospital--let alone prolonged and comprehensive treatment and diet--came to the hospital only when their conditions were incurable. The hospital, in spite of its intentions and services, managed to serve only the relatively affluent. (T. Vijayendra 1982:35)

How can a mission manage a hospital in a country where the annual inflation rate is in triple digits? Drugs and supplies must be purchased from faraway places, with all of the attendant transport, spare parts, credit, insurance, and communication difficulties. This is not even considering the problems of "lost goods," inefficiency, mismanagement, and customs bribery which plague many of the ports, airports, and post offices of the world.

Another Significant factor that is frequently overlooked is the cost of indigenization. That policy of replacing missionaries with equivalently trained nationals is right and 9ood. But the missionary doctor or nurse comes free to the mission hospital, since their support is generated from churches and friends from abroad. When the national physician replaces the missionary, his salary and fringe benefits become part of the hospital's budget. To completely indigenize the professional staff of a typical three-doctor mission hospital would probably add the local equivalent of $125,000 to the annual budget.

This financial crunch makes it difficult for the mission hospital to continue to care for poor people as it originally intended. Instead of patients arriving at the hospital on foot or by ox cart, the affluent who can afford medical care now come by automobile.

B. Secularization

The gradual shift of many Christian institutions toward humanism or secularization is real and perceptible. This is not different from the drift of most institutions, including the great universities on the East Coast of the U.S.A. which were originally founded for Christian purposes.

Dr. David J. Seel, a veteran medical missionary in Korea, notes the following sequence of changes:

(1) The mission hospital becomes a teaching center.
(2) Compassionate outreach is diverted into clinical excellence.
(3) Personalized care is changed to bioscientific impersonalism.
(4) The witness of the heart is twisted into the arrogance of the mind. Far too often the thrust of academic priority, the drive to professional excellence, and the pride of technologic progress have quenched the compassion that burned in the hearts of the pioneers. (David J. Seel 1979:6)

It should be noted, however, that the teaching phase is not necessarily synonymous with secularization, and is not always a diversion from "compassionate outreach." There are examples of mission hospitals which are purely curative yet have become very effective teaching hospitals. In doing so they have multiplied their Christian outreach opportunities.

If the people managing the mission hospital are not mindful of the constant drift toward secularism, the mission hospital can become a place of physical healing, where nurses and doctors are kind, compared to the government hospitals. . .but where there is little appreciation of what healing is in the New Testament sense, and that this is hardly ever practiced. (Robert G. Cochrane 1959:14)

C. Relationship with the Indigenous Church

How should the mission hospital relate to the indigenous church? Each of the many ways of answering this question has been accompanied by problems. Consider briefly the two extremes.

Some missions have completely turned over the hospitals to the indigenous church. In such cases, the national church leaders often find themselves spending more time and energy related to the affairs of the hospital and its large cash flow than to the church with its more limited cash flow. Many national churches are not prepared to handle this kind of responsibility, and the task becomes overwhelming. One wonders how many Christian agencies who turn over hospitals to churches in the Two-Thirds World are themselves still maintaining hospitals in their own country.

Missions which have not turned their hospitals over to the national church must constantly explain why they have not done so. Unless the explanation is worked out carefully within a strong, ongoing church-mission relationship, the seeds for distrust, misunderstanding and disharmony may be planted.

D. Mission Strategy

Modern medical institutions are costly' and require skilled personnel. As missions make this kind of investment, it is important that they have a very clear idea of how the medical work fits into the overall ministry of the mission and the local church. Unless the role of the hospital in the overall context of the mission and the church is understood by all concerned, there is ample room for frustration and failure.

E. Government Control

Host governments, through their Ministries of Health, are understandably exercising increasing control over the hospitals and clinics located within their boundaries. Mission physicians and administrators have become sensitive to the need for open and frequent communication with the proper officials in government. Mission hospitals in general want to fit into the national health care scheme, although this often places certain restrictions on them. Cooperation between the mission hospital and the government may be difficult or nearly impossible, however, in cases where there is open antagonism or aggressively conflicting belief systems.

Occasionally, the host government will identify with the good work being done at a mission hospital by financially supporting some of its budget. This is the case, for example, with the Raleigh Fitkin Memorial Hospital run by the Church of the Nazarene in Swaziland. The mission runs the hospital, but 85% of the financing for the hospital comes from the government. As of January, 1986, the hospital had ten missionary physicians, one part-time national physician, and a full-time Swazi administrator. (Paul D. Wardiaw 1986) In this case, the mission and the government cooperate smoothly toward mutual goals, and there is no restriction on the Christian witness in the hospital.

There are obvious inherent risks in the relationship of the mission to the host government when it comes to hospitals. With each governmental change in a Two-Thirds World nation, the mission hospital is potentially jeopardized. Some governments have simply taken over the mission hospital(s), while others have imposed restrictions. All in all, increased government control over mission hospitals has not made the task of maintaining medical missions any easier.

F. Excellence versus Relevance

In administrating a mission hospital, the question frequently comes up concerning the appropriate level of medical care at the hospital. How sophisticated or modernized should a mission hospital be? Should it have an intensive care area with all of its attendant monitoring equipment? Should complex surgical or medical cases be accepted which tie up the hospital's personnel and resources for extended periods of time? What percentage of the budget should be spent on the newest diagnostic or therapeutic electronic equipment?

What is our concept of "quality care" in a hospital? The very idea of a hospital varies according to a culture. Should the hospital have floors spotlessly clean at all times? How about fresh, laundered sheets on each bed every day? Should the hospital provide three nutritious meals per day to each in-patient? Should the wards be air-conditioned? Should there be such restrictions as limiting visitors or visiting hours? Is it allowed for the mother to sleep under the bed of her hospitalized infant?

In a sense, it comes down to who makes the decision about "quality care" and "appropriate technology." Each situation and culture is unique, and there must be allowance for considerable variance in the way different agencies and churches answer this question.

G. Understaffing

Mission hospitals never seem to have sufficient staff. "Three RN's, a doctor, and a medical laboratory technician are immediately needed." (Milan Springle 1986) The staff on duty always seems overworked. This combination yields the predictable "burned out medical missionary syndrome." Not being able to draw the line when someone's life is always at stake, the medical missionary tends to overextend to the point where he suffers from spiritual, physical, and emotional exhaustion.

Precisely for this reason, several agencies have come to the decision that one-doctor hospitals are unfair for all concerned, and will not be permitted within their organization. The AGAPE movement of Campus Crusade for Christ has decided to deliberately overstaff its medical facilities. (Ron Baker 1986) By overstaffing they find that there is adequate time for spiritual ministry instead of all the time being consumed by physical emergencies. Overstaffing of mission hospitals might be a way to enhance the missionary doctor's family life, avoid the burned-out syndrome, and, possibly, to permit a longer career with the mission.

III. The Health Gap

What are the dimensions of the health gap between the haves and the have nots? According to 1982 statistics, the life expectancy of a baby born in an industrialized country was 74 years. Only eleven babies out of every 1,000 newborns died before their first birthday. Safe water, proper sanitation, good nutrition, adequate shelter, full immunization, and a basic education is the privilege of most citizens in the top 31 countries of the world. (U.N.l.C.E.F. 1985)

In contrast, the 1.3 billion people living in the 43 poorest nations of the world are struggling to survive. A baby born in 1982 in one of these countries had a life expectancy of only 46 years. In 1983, over 140 out of every 1,000 newborns died before their first birthday. Of the survivors, only 10% will be immunized, 13% will have proper sanitation services, and only 23% will have regular access to safe drinking water. One out of three children under age five years suffers from malnutrition to some degree. Over 40,000 infants and children die every 24 hours in the Two-Thirds World from diseases which can be prevented.

Part of the existing problem is aggravated by the fact that "90% of all health money disbursed by Christian organizations is funneled into curative services at the tertiary level." (Jean Morehead 1985) While hospitals can be very effective tools and will always be necessary, the institution-based approach to health care in the Two-Thirds World is being proven both ineffective and inefficient. Worse still, curative care without coexisting preventive measures may be judged as poor stewardship and unjust.

Instead of preventing diseases through effective health education and the use of available potent vaccines, hospital-based medical care waits for patients to come for treatment of their illnesses. The doctor and nurse are overworked, performing tasks which could just as well be adequately handled by others with less training. At the Mtendere Hospital in Zambia, 54% of the people who came to the Outpatient Department for care had minor complaints which could be cared for by someone other than a doctor or a nurse. Meanwhile, three-fourths of the children under age five years had received no immunization, and half of the mothers interviewed had lost at least one child between the ages of six months and five years. (Maureen O'Keeffe 1973)

Medical missions have emphasized the hospital/clinic-based approach to health care in the past. The lack of success using this approach in improving the general level of health in a community or a nation foretells the bankruptcy of this approach, especially in the face of the current world population growth. While missionary health professionals need not feel responsible for the existing health gap, there are moral and ethical considerations which implore us to work toward closing the gap.

The very existence of the massive difference in the levels of health should motivate us to ask: How can those of us in health care ministries, as servants of Jesus Christ, best assist needy peoples of the world toward improved health? We would like to be part of the solution rather than just part of the problem.

In order to better understand why there is such a large health gap in the world today, there must be some notion of what the basis of health is.

Most people attribute the general level of good health in the United States to the excellent health care system. It is assumed that the 7,000 hospitals, 400,000 physicians, 20,000 nursing homes and other long -term non-mental institutions, 127 fine medical schools, the best research and laboratory facilities in the world, and an active pharmaceutical industry, play the vital roles in promoting the general level of health. This health care system should be important, for it cost the average American $1,580 in 1985, or 11% of the nation's Gross National Product.

However, all of the above are not the major reason for the excellent health enjoyed by most United States citizens. The measurable advances in the general health level of the USA over the past 100 years have been due to

improved nutrition, pure water supply and sanitary sewage disposal, environmental sanitation, and communicable disease control; outside of the medical field, improved housing, education, and workplace safety have been important factors. (Steven Jonas 1981:463)

Curative care is important for individuals but actually does little to improve the general level of health for a population. Dr. W. Henry Mosely, Director of the lnstitute of International Health, School of Hygiene and Public Health, at The Johns Hopkins University, has written:

Carefully documented reports of sophisticated curative medical programs in rural Guatemala for over nine years, and the Gambia for more than 20 years, reveal that they had little impact in lowering childhood mortality. This has been confirmed by my own experience in Bangladesh, where a followup of severely malnourished children cured in the hospital revealed that over two-thirds had died in the six months following discharge. (W. Henry Mosey 1985B:19)

It has been estimated that the presence or absence of medical care accounts for only 10% of the difference in mortality between different populations. (V. R. Fuchs 1974) The ability of modern medicine to alter the natural course of disease is greatly exaggerated by the public at large. (Edward J. Burger 1974)

Advances in medical knowledge had little effect on the death rates from childhood diseases like whooping cough, measles and scarlet fever. Deaths from these diseases declined to a low level long before there was any treatment for them, and decades before the organisms responsible for them were identified.

The history of tuberculosis, "the galloping consumption" of the 18th and early 19th centuries, gives additional evidence that success in the fight against TB did not come mainly from medical science. The death rate for tuberculosis was 4000/million in Britain in 1838. This rate had already fallen to nearly 2000/million by 1880 when Robert Koch discovered the bacteria responsible for the disease. By 1945, when the first effective drug was discovered for the treatment of TB, the annual death rate was down to only 500/million. The introduction of anti-tuberculosis therapy has merely continued the decrease in the number of deaths from that disease at the previous rate.

Improved health in the industrialized nations is mainly due to improved diet, public health and hygiene, and medical science, in that order. But another influence needs to be named, without which permanent improvement in the level of health would have been impossible. This is the change in reproductive behavior which caused the birth rate to decline.

For the general level of health of a people to improve, there must be both economic development and a declining birth rate. This is becoming painfully obvious in the Two-Thirds World. "Unless the under-five mortality is reduced, security for the old age provided, and agriculture becomes profitable, no amount of propaganda or incentives will convince poor village people about the benefits of a small family." (U. N. Jajoo 1985:220)

The conclusion must be drawn that non-medical factors, such as the environment and the economy, play a more important role in reducing mortality and morbidity rates than does curative medicine. Thomas McKeown studied 300 years of health statistics in England and concluded that "factors unrelated to medicine--such as increased food supply, sanitation, and decreases in population growth rates--were the primary cause of improved health nationwide." (Thomas McKeown 1976:265)

Dr. Hyo-Kyu Kim, Vice President for Medical Affairs at Yonsei University Severance Medical School in Seoul, Korea, has written:

Economic development alone, without intentional public health programs, is accompanied by some improvement in public health. Korea, with its recent economic growth, is a good example. In the last 20 years, Korea has achieved a great deal of economic development. But, like some other developing countries, health has not been a priority. During the period, the share of the national budget appropriated to health and social affairs has not exceeded one percent. Despite the lack of priority for health, it improved along with economic development. Life expectancy rose from 55 years to 70 years; and mortality and morbidity patterns have improved too, without any effective health programs during the past 20 years. During the same decades, per capita GNP rose from $70 in 1960 to $1270 in 1978. Rice production level has come close to self-sufficiency. Education is compulsory up to the sixth grade as of 1980, and is considered one of the most important elements of economic growth. (Hyo-Kyu Kim 1980:13)

If we look at curative care as being necessary only for those medical/surgical problems which cannot be prevented, then they are viewed in a more realistic light. Maybe Plato was right when he wrote in his Republic that the need for many hospitals and doctors was the earmark of a bad city.

It is so easy to concentrate our attention on the spectacular events occurring in the area of curative medicine, such as 100,000 coronary bypass operations annually, that we completely miss the fact that if preventive medicine were practiced, the need for such heroics might be much less. As Rene Dubos has written: "To ward off disease or recover health, men as a rule find it easier to depend on healers than to attempt the more difficult task of living wisely." (Rene Dubos 1961:114)

Medical missions has pioneered in the introduction of Western medical practice into many countries. Our record in curative care is superb. But to this point our performance in preventive health care is not quite so good. In view of the difficulties experienced in maintaining mission hospitals and the tremendous and widening health gap which exists among the peoples of the world, the time is ripe for a fresh look at creative solutions. The next two chapters will consider one of these solutions, the concept of Primary Health Care (PHC).

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