Development: Genuine Change Through Partnership
What is the role of Christian healthcare professionals in authentic community development? Dr. Mark Crouch discovers this topic in the cover story from the winter 2017 edition of Today's Christian Doctor.
by Mark Crouch, MD
A few years ago at Kudjip Nazarene Hospital in Papua New Guinea, our HIV clinic conducted a quality-improvement project under the supervision of an international non-government organization. We set out to measure different metrics of our facility’s performance in caring for our patients living with HIV. As a staff physician heavily invested in our primary health services, I spent several late afternoons combing through our paper charts ticking various boxes in the data entry forms. Once compiled, an excel spreadsheet and graphs showed where we needed to make adjustments. I sat down with the staff and walked through how we could improve our care. As we implemented things like regular weight checks with newly purchased scales and changing our encounter forms, I felt proud to see our metrics improving. However, after a few short months, I noticed some of the old habits and patterns had returned. Only after more serious reflection did I realize that, although well intentioned, I had personally spearheaded each of the changes our facility made, and the staff may have felt little ownership of the new direction we took. Unsurprisingly, many of the project’s (my) successes began sliding away. What could I have done differently to effect a lasting change that would ultimately help our patients?
Many Christian healthcare professionals engage in outreach efforts to those lacking healthcare, both domestically and abroad. Whether in a local U.S. community or an international setting, healthcare workers often take it upon themselves to care for those neglected by society. The unique and specific help we can provide to the underserved makes a compelling argument for more Christians working in healthcare reaching beyond their own practices into volunteerism and healthcare ministry.
However, the role of the Christian, and in particular the Christian healthcare professional, can be problematic. Charitable clinical services can easily become “handouts” or “Band-Aids” when, for most communities, the true need lies in authentic development. A balance must be struck between providing tangible help—for example, a physician volunteering to see patients for free once a month in a temporary clinic—and true development, such as a mobilized team within the neighborhood tackling issues like poverty and education in addition to health needs.
How Christians approach the development of a community in a healthy way relies on their understanding of what poverty truly is, what authentic development looks like and how to go about it in a way that honors God’s heart for the poor and needy. Pivotally we need to ask, “How do we grasp the hands of the poor and hurting without crippling their ability to develop their own right relationship with the Lord?” Without addressing this question, well-meaning efforts to relieve suffering among the sick may result in an unhealthy cycle of charity that damages both the poor and those working to serve them.
THE PROBLEM OF POVERTY
Efforts to help the sick or poor may result in more harm than good, if these efforts are not approached in a way that respects the sacred position these individuals occupy in God’s redemptive plan for our world.
One of the barriers to working effectively with the poor rests in having an inaccurate, or at least incomplete, understanding of poverty. Outward manifestations frequently associated with “poverty” might include dilapidated housing, no savings or lack of a vehicle. In fact, lack of material possessions may represent the most common understanding of being poor. As healthcare workers, we also understand that a person’s poor physical health will have a profound impact on their life—employability, fulfillment, quality of life and ability to relate with friends and family. While these circumstances certainly create hardships, the true root of poverty goes much deeper than possessions and physical health.
Poverty can be more fully understood as a fracturing of relationships. The poor suffer broken relationships with God, others and themselves. This definition of poverty, with varying degrees of application, captures those with and without earthly goods. For example, broken relationships could include feeling powerless in a political system, disconnected in a social system, inert in an economic system or, tragically, robbed of purpose in a spiritual system. Because of these issues, some of us also lack possessions; yet it is important to recognize that materially non-poor individuals can experience just as many broken relationships as the materially poor. The affluent workaholic physician may have poorer relationships than a patient living on food stamps. But the materially poor often feel the most trapped or powerless in their situation.
A Christian healthcare worker serving among an impoverished and unwell community can make an incredible impact. Removing physical ailments of someone robbed of purpose may ignite the flame leading to their continued renewal. This impact cannot be overstated, and as Christians in healthcare, we ought to follow Christ’s example in providing genuine, tangible benefits to others through our profession. However, the ability to make a profound difference in the lives of the poor can result in an inflated sense of purpose among the health worker. If I allow it, my service to others through healthcare could result in me assuming a role in their lives that ought to be only God’s to fill. This “god-complex” not only breaks my own proper relationship with God, but it can also be harmful to my patient’s ability to connect with Him as the true Healer.
So to avoid creating an unhealthy and further disempowered identity in my sick, materially-poor patient, and to refrain from taking God’s place in their restoration, I must find a way to help their situation beyond a charitable handout.
TANGIBLE HELP, AUTHENTIC DEVELOPMENT
In our rural area of Papua New Guinea, a team of individuals recently came from the U.S. to assist with construction of a block of toilets in the local community. While talking to a national friend of mine, he asked, “Do they think we don’t know how to build things here?” He went on to suggest that men from his tribe could have built this and would have gladly taken the extra work. I have struggled with his observations. While the utility of short-term missions is beyond the scope of this article, my friend’s comments illustrate one of the unfortunate patterns slowly dominating how the materially non-poor approach service to the poor.
Many of the efforts currently taking place to assist the poor both in the U.S. and abroad do not create sustained development of individuals or communities. Often, these include providing services such as health clinics, food distribution or construction of housing. These types of projects might be better called relief efforts, rather than true development. While these things can be a catalyst in the lives of individuals, they can also create unhealthy dependencies. If these outreaches foster attitudes of helplessness, they can actually hurt the development of the people or communities they attempt to help.
A proper approach to development needs to include, but move beyond, providing material assistance. While donors may appreciate measurable output like patients seen in a clinic or construction of a building, true development lies in creating a sustained change in a community. This change only happens when the intangible outcomes are given as much importance as the material. Specifically, service among the poor must include the spiritual and personal development of both those receiving and providing assistance. These aspects ought to be included alongside material support.
Because the root causes of many forms of poverty lie in broken relationships, including a broken relationship with God, spiritual restoration needs to be integrated into any form of development. Some of the most crippling attitudes and behaviors spring out of an improper worldview based on erroneous spiritual beliefs. If one believes their poverty is destined by higher powers or a fate beyond their control, they will make little or no effort to escape it. For those who endeavor to bring relief of suffering, spiritual wholeness is a must—including a right relationship with God, others and, where possible, a local church.
Development also needs to include investing in individuals who will, usually, outlast any outside actors in the community. A pastor or other leader who takes initiative to improve themselves and their neighbors will have a deeper and more sustained impact than an outsider. When working among the materially poor, those wishing to serve them ought to mobilize that community’s pre-existing change agents and provide training and encouragement for their endeavors. This requires adopting a mindset that appreciates the strengths already present in the community, as well as approaching them in a humble and teachable way.
The terms often used to describe efforts among the poor include “service,” “giving” and “helping.” However, such terms involve an intrinsic direction of assistance. As we have seen, the root causes of poverty revolve around dysfunctional relationships. Thus, the materially non-poor can be in as much need of “help” or “service” as those they work with. For those who choose to use healthcare as a ministry for the materially poor, adopting a partnership approach may create a healthier relationship.
Commonly, the first step in determining how to help those in poverty involves conducting a “needs assessment”—enumerating the challenges facing a community and identifying how to best remedy them, which occurred in my HIV project. While on the surface this approach seems to get the job done, it can further damage the relationships of those it aims to help. Emphasizing the needs and negatives in a community can further impoverish them, pointing out that they have many problems and need outsiders to give solutions. Sometimes, a community’s worldview or beliefs might involve a fatalistic approach to their own suffering. In this case they may be incapable of identifying needs, seeing them as a just end for perceived wrongs or fate. Focusing on needs may reinforce this false worldview.
An alternative to the need-based approach is directing efforts toward strengths. Rather than asking the materially poor what they lack, we could ask what they do well. What skills and resources already exist? Who might already want to improve the health of this community? How can these things be encouraged and leveraged to combat the issues facing us? Identifying the intrinsic assets of a community, especially individuals who can bring about change, should occur alongside, if not before, identification of needs.
Working with the poor also demands a reoriented time frame. This is one of the most difficult aspects where I work in Papua New Guinea. International non-government organizations with substantial funding and managerial support prefer to work on projects such as housing, teaching or relief efforts. However, a long-term investment represents the best way to see true development in an impoverished community. Numerous efforts at our hospital have involved aid agencies providing financial and logistical support for a few years. Once this initial investment ends, any gains made may revert to previous form.
Often times this happens because “outsiders” do not appreciate the cultural differences of the community. This occurs both for those reaching across town or around the world. The understanding of time, relationships, spirituality, justice and other critical life-framing ideas would be radically different between an affluent metropolitan suburb and those living in material poverty of the inner city. Christ invested 30 years in the culture around Him before beginning His public ministry. Why would He do this? He created the world and the people He came to reach, but He saw value in a long-term strategy that involved being an established part of His community before trying to effect change. Those who wish to partner with the poor must adopt an investment mentality rather than a project-oriented one.
Critical to being a partner with the poor is having the approach and attitude of a learner when joining them. This has been the best, and most difficult, lesson for me to learn. Those we wish to help probably have more to teach us than we offer to them.
When a second improvement project came to our hospital, revolving around the tuberculosis program, I adjusted my approach. I wanted to know how Papua New Guineans felt we could do better. Our staff generated a variety of ideas and I listened with an occasional observation or suggestion. Our clinic already performed very well in screening tuberculosis patients for co-infection with HIV, but the staff felt this was an important area to improve. I struggled to understand this, since we already exceeded the targets set by the national department of health. However, they requested a partition be placed in the clinic to give patients more privacy to be tested and receive their results. Apparently, they knew our patients better than I did, because our screening rate increased from 76 percent to 99 percent with this single, inexpensive change. What I didn’t foresee was it also created a new space in the clinic to organize our medications for more efficient dispensing. This allowed staff time to provide patient education, conduct follow-up visits, keep track of those who “defaulted” on their medicines and store more valuable equipment. My Papua New Guinea brothers and sisters have taken ownership of this new space and use it to give Christ-like care to our patients. Had I, again, spearheaded the efforts of this project, I would have missed the extremely valuable input and ideas of the staff members who understand our patients and culture much better than I ever will.
EARS TO HEAR
On a sunny weekend day, I stood looking at what I thought would be a failed construction project. I needed to build a fence separating my yard, where our children play, from the road nearby that carries heavy maintenance vehicles. Some power tools lay scattered about, as I was sure I would need them. I had cut bamboo fence posts and hammered them into the ground, but I couldn’t find bamboo of the proper size to serve as the crossbeams. I contemplated carrying all of my bamboo to the hospital’s workshop and attempt the dangerous task of cutting the curved wood on the table saw. A local villager, who worked security for us, came by and asked what I was doing. After listening to me bemoaning my plight he said, “Dr. Mark, you have plenty of bamboo that will work just fine. Where is your bush-knife?” He proceeded to perfectly split my bamboo into crossbeams using just a machete in a fashion I, unfamiliar with my setting and my materials, wouldn’t have imagined possible. In an hour, my fence was completed.
As Christian healthcare workers, we often possess good clinical skills and high credentials. Because of God’s work in our lives, we often feel compelled to serve the poor. The tendency may exist to use our own methods and the high-vantage of superior knowledge to bring about changes that do not suit, or even hinder, the physical and spiritual development of those around us. But to guide others into a proper relationship with God while ministering to them physically, we should adopt the approach of Jesus. He lived and learned among us before beginning His public ministry and, when He did, approached the suffering people of His day in a humble spirit, partnering with them toward a heavenly destination. For the Christian healthcare professional working among the materially poor, we should consider our partnership with them a gift, learning from them and embracing their strengths while we jointly pursue a more Godly life— for us and for them.
Thank you to the staff of Nazarene Health Ministries - Primary Health Services for allowing me to learn from and partner with them the last few years. Thank you to Johanna McLendon for inspiring my thoughts on this topic.
When Helping Hurts by Steve Corbett and Brian Fikkert
Walking with the Poor by Bryant L. Myers
Toxic Charity by Robert Lupton