MISSION HOSPITALS - DYING RELICS OR FUTURE FOUNDATION

by

Richard H. Hart, MD, DrPH

The Challenge

   The Seventh-day Adventist church has been known worldwide for its health and educational services. For. years, foreign travelers were advised to seek out SDA health care institutions for the best available medical care. Through years of hard, creative work and sacrifice, Loma Linda's alumni have been instrumental in establishing most of these hospitals,. The names of these institutions - from Malamulo to Montemorelos, Mwami to Manila, to name just a few - are synonymous with the history of the church and LLU and recall some legendary giants from our past.

   Today, the church operates over 160 hospitals around the world. Half of these are in the U.S., with another 10 in Europe, the South Pacific, and some of the more developed countries of Asia, The remaining 70 are in the developing countries of the world - 25 in Africa, 1. 3 in southern Asia, 10 in the Philippines, arid another 15 in Latin America. Each of these institutions was established in an area of great medical need. With roots in the first half of this century, they set the standard for medical care, with creative western doctors being ascribed almost magical powers to heal. Most of these institutions have also spawned a network of rural clinics.

  Unfortunately, the last two decades have dealt harshly with these institutions. The quality of care has dropped dramatically as weakening economies, shrinking overseas budgets, changing national and church politics and other factors have taken their toll. Too many institutions have slipped from setting the. gold standard to dragging the bottom, with national governments and our own leaders wondering whether it is worth continuing this deplorable state of affairs. Understandably, staff morale suffers greatly in these situations. Even the normal upbeat attitude, evident when Christians gather together, is lost and gloom often reigns supreme making witnessing about God's love and care very difficult. Various committees (of which I have occasionally been a member) felt that the only reasonable alternative for saving the name of the church is to close some hospitals to avoid embarrassment and further erosion of our somewhat tarnished image. Ironically, the same organization that runs some of the premier medical institutions in the world now also tolerates some of the poorest institutions.

   In recent years, a growing number of us at Loma Linda University, the General Conference, and elsewhere, have become increasingly concerned about this rapidly deteriorating situation. Lengthy philosophical discussions have centered on such questions as: is health care a necessary part of our legacy in all parts of the world; are we simply trying to place too much on the back of a ten million member church; or if indeed the era of medical missions has passed and we should consider other avenues of service.

   While opinions vary, the consensus has been that if the medical need still exists, then our Biblical commission to teach, preach and heal is still valid. More importantly, loss of our international commitment and interest could fundamentally undermine what this church is all about and what Lorna Linda University has come to embody. In the eyes of the world, we have proudly and appropriately been defined as a people with a real and practical commitment to humanitarian service. To back away from this challenge now would seriously question who we are and what we stand for.

   A quick survey of most developing countries will convince anyone that the need is still real and, in fact, probably greater than it has ever been. Except for a few of our city hospitals, we are often the only source of health care for surrounding thousands, while the quality of care in many government institutions remains very marginal. Most developing countries are now averaging between $5 and $10 per person per year on all health care expenditures, with no improvement expected soon. After an initial flurry of interest in taking over all health care institutions in the years after independence, most governments now recognize their own financial and managerial limitations and are requesting churches to stay in the health care business, offering to return some of the previously nationalized hospitals. Ethically, it is difficult to bow out on the basis of mission accomplished".

   If we agree the need and purpose are still there, the next logical question is whether we can financially and professionally manage 70 hospitals and " health care systems" in marginal economies with a weakening donation base. The number of "inter-division" or expatriate budgets used to send missionaries has significantly decreased in the last few years. New funding mechanisms will need to be developed if we are going to -find and maintain professionals. Even if the money were available, are there physicians and others, from Loma Linda University and elsewhere, still interested in international service? While these questions can only be answered in time, it seems inappropriate and even unbiblical to give up in the face of what are seemingly insurmountable difficulties- Our church and professional forbearers would not understand our lack of courage and commitment. Even more importantly, would God?

The Plan

   Given this established need, numerous discussions with church leaders and health professionals have focused on possible options for the future. While many issues remain to be discovered and resolved, there is a surprising consensus emerging in some areas. Let me summarize these quickly and indulge your understanding that while these are major issues, I am convinced that the statements and implications are valid.

  

   It is against this background of issues and assumptions that the concept of Adventist Health International (AHI) has emerged. A new model of partnership win be offered to those countries desiring assistance. Individual AHI country organizations would be established which would include three corporate members - the local union where ownership of the institutions would generally remain, the parent division representing the General Conference, and AHI. AHI's involvement would bring access to some new resource,,,, but more importantly would establish new management standards that would reassure potential donors and employees. Through this network of local country corporations with improved management techniques, strengthened professional staff, arid new financial and physical resources, SDA health services could be upgraded arid maintained at an acceptable level.

   The enormity of this task is frankly overwhelming to even the most stalwart among us. It was decided to try our theories out in several areas before speaking publicly about it. Following discussions with church leadership, two countries were identified with critical needs. These were Guyana in South America, a part of the Caribbean Union of the Interamerican Division, arid Ethiopia, a part of the Eastern African Division. We agreed to take up the challenge.

   Davis Memorial Hospital (DMH) in Georgetown, Guyana was on -the verge of closing, Contributing factors included a weak national economy, political isolation from donors, difficulty recruiting doctors, and the management and morale problems typically seen when an institution is dying. Patient count was approximately 5 patients per day, The hospital required heavy subsidy from the Caribbean Union. With a promising national administrator, Mike Kendall, finishing his Masters in Health Administration at Loma Linda, and an open spirit of cooperation from the union and division, we took DMH on as our first challenge, The story of this institution and the building of positive momentum, are told elsewhere in this journal by Mike Kendall and Faye Whiting, '90, an obstetrician/gynecologist from LLU, who agreed to be a pioneer in this project.

   Though far from completion, the, initial success in Guyana led us to accept another request from the General Conference for Ethiopia, With a membership of over 200,000, the church originally had four hospitals - Gimbie, Debra Tabre, Dessie and Empress Zauditu, our flagship in Addis Ababa. We lost all but Gimbie to the communist regime who came to power after Emperor Haile Selassie. Now, despite stable national politics once again, Gimbie was being threatened due to meager resources, deteriorating physical plant, limited professional staff and all the usual problems of a rural hospital. With the hospital serving a 200,000 population in Gimbie town and over two million in the surrounding area, the government recognized both the need for the hospital and its increasing inability to service that need. An ultimatum was issued in early 1997 for the church to upgrade Gimbie or the government would be forced to close it down or take it over. While the government's other options were not good, this written protest about the quality and capacity of our institution served as a "wake-up call" to the church.

   The challenge at Gimbie was greater than that of Guyana! A new building would need to be constructed to expand the very limited 70-bed capacity and almost non-existent support services, Gimbie Hospital was built by the Italians in the 1940's and very little has been done to the main hospital buildings since that time. Though three national doctors and one Filipino surgeon were on staff, their meager supplies and support greatly hampered their ability to utilize their skills. After an initial site visit in September, 1997, the Center for Health and Development at the School of Public Health agreed to take it on and Rind raising began with plans to start construction during spring break of this year. A team of 28 SIMS students and faculty from LLU joined a group of 8 volunteers from Holland in March to begin construction and establish a new system for both Gimbie and the 14 clinics scattered throughout the country. Even more importantly, plans to establish AHI-Ethiopia were begun with extensive negotiations with the Union, Division, and General Conference. Objectives were established and legal papers were drafted.

   Located in the western highlands of Ethiopia in an area of beautiful rolling hills covered with farms and woods at an elevation of 7,000 feet, Gimbie is a 10-hour hard drive from Addis Ababa, from where many of the building supplies needed to come. The challenges of a new building were real. After four months, the foundation is in, and Gene Witzel, recently retired after a distinguished building career in Africa, is leading in the completion of construction. An AHI-Ethiopia board has been established, staff are being recruited to fill the open positions, and some positive momentum is starting to build. Donn Gaede, one of our health administration faculty in, the School of Public Health, recently spent a month at Gimbie, conducting in-service training for the administrative team.. To date, around $200,000 has been raised for the new building and to reestablish the pharmacy, lab and x-ray. These funds have come from a variety of large and small donors, both inside and outside the church, and another $150,000 or so will be needed before Gimbie can be expected to maintain itself Plans call for a new 14,000 square foot, two story building that will enable Gimbie to meet its obligations. A strategic plan has been developed that can lead Gimbie back into full service and provide a solid foundation for future expansion and the development of service and training programs in the country.

   The initial successes at Guyana and Ethiopia have led us to believe that the basic premises of AHI are sound and may be applied elsewhere. The amount of energy and time required in each country does mean that no more than 2 or 3 new initiatives can be attempted at a time, at least until a larger resource base can be established. While the burden so far has largely been carried by LLU, the Adventist health systems in this country, Maranatha, ADRA, and ASI have indicated their interest in participation. Requests are coming in from other mission hospitals, but it is important that a solid foundation with quality personnel and policies be developed in each area so improvements will be maintained.

The Commitment

   Many hours of discussion and reflection on these humble beginnings have led us to affirm the three unifying goals of AM - Spiritual, Educational and Community Development

   Spiritual-Development must remain a dominant reason for our involvement anywhere and should be interpreted to include all aspect,,,, of a balanced spiritual growth. We must staff institutions and design management systems that not only allow but encourage our personnel to be active in the integrative care of the whole person- This includes a complete understanding and sharing of the liberating and ennobling power of the gospel. While relationships with governments and non-church donors requires a careful and ethical balance of service and witness, we should always keep spiritual development as a fundamental commitment.

   Educational Development of the local people includes a commitment to regular academic programs as well as continuing education of staff and others. Development of quality training programs at appropriate levels should once again be a hallmark of SDA health services. This will not only provide valuable staff for our own institutions, but also permeate the rest of the health care services in the country with our philosophy and caring approach. Staffing, equipping, and maintaining educational programs is expensive, requiring support linkages with similar educational programs elsewhere. Plans are under consideration for establishing training programs at Davis Memorial and Gimbie. Continuing education for our own staff, at all levels, as well as employees of other organizations, is another valuable contribution that should distinguish our system.

   The third goal is Community Development. We must look beyond our four walls to the communities around us. In too many of our institutions, people are dying from common preventable diseases within sight of our compounds, just as they have for generations. Many community programs can be developed that attract external funding and create a positive influence for miles around. We simply must avoid being so caught up in the unending crises of the clinical world, that we neglect the long term impact of community education and initiatives.

   This triple commitment to Spiritual, Educational, and Community Development must be supported by solid clinical, programs and effective management systems. The core business of AM is health and we must maintain quality at an appropriate technology level. Each country must also move toward a certain level of financial self-sufficiency. While it is appropriate and necessary to concentrate extra resources during the reestablishment phase, strategies for cost recovery and internal self-sufficiency will be built into each strategic plan. This is more difficult in some locations and economies than in others. Eventual sharing of resources, including financial, may be required if the broader objectives are to be met.

   In summary, I would reiterate the enormity of the challenge ahead. Even the most far-sighted among us has trouble knowing where this will lead. We are clear, though, that our reasons and objectives are consistent with. Christ's mandate to all Christians to teach, preach and heal. We earnestly covet the interest, input, and support of our alumni. Some may have a particular area or institution in which they are most -interested. We will need prayers, funds, personnel and assistance from many, in more than token amounts, to accomplish these objectives. While the war stories of the past are too often true (and some will need to share them again) it is time now to move boldly into the future with hope and optimism