The Most Rev. Katharine Jefferts Schori: Health Care and the Church
Health and healing across the world and across the street: collaboration between the religious and health care communities in global and local contexts
by Katharine Jefferts Schori
12/3/2010
The work of clergy has anciently been called the "cure of souls" and in some places, a cleric's locus of work is still called a "cure." Pastoral ministry is focused on the care of human beings, "soul" being shorthand for the whole person, even if the fact that it's shorthand has been forgotten in some times and places. Cure and care are intimately related, including their origin in words that mean to have concern for, or even lament or grief. Cure and care are equally the focus of the medical world. In recent decades we've seen an expanding recognition that cure and care have to do with far more than the remission of acute symptoms in a particular body part. There have been strands in both religious and medical traditions that have understood healing to be about a larger vision, but they haven't always been seen as the avowed purpose, or the public center, of either tradition.
Healing is directly related to health and wholeness, and to holiness. In English those words all come from the same root, and have to do with continuing in, or moving toward, a desired state of being, or something more closely approximating perfection or completeness. The Abrahamic religious traditions uphold a vision for the healing of all that is, human beings individually as well as in community, their relationships to the divine, and the relationships among all the various parts of creation. That vision is variously called tikkun olam, the repair of the world, shalom, salvation, or the reign of God. Shalom in Hebrew, or salaam in Arabic, is a kind of shorthand for that prophetic dream of a healed world, and it underlies the ancient prophetic insistence on the need for multiple forms of healing, leading to a world of justice and peace. That dream includes the healing of individuals as well as communities and nations, and insists that all have access to the blessings of life - food and adequate abundance for a feast, shelter from the elements as well as war and violence, and the kind of health that lets each one live an active life, productive and full of years. That vision insists that right relationship with the earth and the rest of creation, as well as the divine origin of all those blessings, is part of that overarching dream.
Salvation may seem like an unduly loaded theological word for that concept, but at its root it also means healing - and the etymological connections are far more evident in the romance languages than they are in English. The Syriac church in Baghdad bombed a month ago is named Our Lady of Salvation; its French name is Notre Dame de Salud - Our Lady of Health (or Salvation). That word is as much about health and wholeness as it is about rescue. Salvation at its deepest and most eternal is beyond any narrow understanding of soul as somehow separate from the rest of a human person, or an individual disconnected from community.
This dream of a healed world, offering health and wholeness to all humanity, underlies many religious traditions and medical care. Our respective goals overlap, at the very least. We are natural and appropriate partners in the healing endeavor, seeking healing for all. When we begin to look at the causes of health in human beings, we also quickly see that the health of political systems and ecosystems are major contributors, and a robustly healthy human community is intrinsically impossible in their absence.
Let's start with the immediate and local. What do we know about the role of spiritual care in treating disease, or in supporting health? Broad-based epidemiological studies show that people who participate regularly in worship, attend gatherings of faith communities, and have an underlying system of meaning in their lives enjoy better overall health, tend to do better in response to the challenge of disease, and live longer than those who lack such assets. Provision for spiritual care has been a required part of federally funded hospice care for many years, and it is now also an expectation of Joint Commission (JCAHO) certification. The medical care community is far more aware and supportive of interactions with spiritual care providers than it was twenty years ago - even if HIPAA has made it harder for providers to get access to patient information! It should be regular practice to query patients about their spiritual systems, community of support, and their desire for access to spiritual care. Caring for the whole person requires this as best practice, and it is an essential part of the hippocratic oath. Chaplains can be an enormous resource in the work of connecting patients to their own spiritual support systems, and their healing work is facilitated by your encouragement and referral.
Medical care providers themselves benefit from spiritual communities that support meaning-making in the face of life and death decisions. How and where do you find the inner resources when you've signed too many death certificates or delivered too many terminal diagnoses? Your own full humanity - and health - require making some connection to larger questions of meaning. Most of you were drawn into the healing arts out of wonder at the human body and its capacities, or your desire to help others - or both. Those motivations partake of transcendence - connection to something bigger than an individual - and both are nourished and encouraged to grow and deepen in company with others who share an understanding of being part of something larger, lasting, and, if you will, eternal.
Let me suggest another significant place of connection, having to do with the moral or ethical value of the decisions you are making, and helping your patients to make. Given the direction and rapidity of medical developments, diagnostic tools, and methods of treatment, ethical reflection is absolutely essential - and in more rapidly responsive ways. We need to be considering, together, whether particular approaches and specific protocols are not only doable, but should be done. Even when entire communities are unlikely to reach consensus on approaches and protocols, we need to have the conversations and explore the parameters. That work can help patients and families to make informed decisions congruent with their own values and beliefs in time of crisis.
There's another aspect of ethics committees and similar bodies that is less often addressed. Much of that intensive work focuses on the local - what should be done in this case, with this 47 year old male with acute myelogenous leukemia, or this 90 year old female with a broken hip and advanced dementia? But how often do we shift the focus of our lens to the larger community and its health? How much ethical reflection focuses on the ability of an entire hospital system to improve health, or the choices a medical practice will consider in treating severe birth anomalies in a heavily industrialized area? I submit that these are not decisions that should be left solely to "management." Communities of ethical discourse can encourage management to shift its gaze - at least in part - toward issues of health in the larger community, and the religious community can be a significant partner in that expansive work. If we are to heal the larger body, then questions of purpose, vision, and mission - for practice groups large and small, and for medical educational institutions - have to be engaged. It is a responsibility shared by the healing communities of both faith and medicine.
Consider some of those larger community health issues - the vastly increased incidence of asthma in poor inner-city environments, or the rates of type 2 diabetes in the same places, often called "food deserts." We're beginning to see rising rates of diabetes in India, as a result of a different but connected problem - sudden access to improved diets. Women in India have borne small and relatively poorly nourished babies for generations. When those children become adults with access to richer diets, they are far more susceptible to diabetes, and at younger ages, than their poorer relatives and ancestors. Native Americans live with a similar problem: the available food is overly processed and nutritionally skewed from the historic range of foodstuffs. Does the responsibility of the health care community extend beyond treating the individual diabetes patient? Does the responsibility of a pastor go beyond praying with a sick person or ensuring that she has transportation to her medical appointments? The epidemic is not going to be healed by addressing the intensely local issue, as necessary as that is. The sickness of God's people is a systemic illness that says that only some deserve access to education, healthy foodstuffs, and early medical treatment. The global disease is about how resources are shared or not shared, and it includes a skewed vision of what a healed world looks like. That primal vision is neither an eternal orgy of over-consumption nor is it living in soul-killing deprivation. Nor does it envision a world where people eat anything in sight because they are bored, depressed, or because truly good food is unavailable.
Part of our shared vocation is to proclaim, advertise, and teach about what health really looks like. That vision of health must include both the particular and the general, the individual and communal, and it must include hope for health among those with "disabilities" or "disease." That may be where the nature of the spiritual teacher becomes most essential. The Abrahamic traditions share a broad understanding of what perfection is and is not. Elements of each tradition understand that healing is possible in the process of dying, as well as in the small dyings that are part of every human life. Grief or loss can produce a more engaged and rewarding life once the loss begins to heal. That does not deny the gift of the life or part of life that has been lost, but it does affirm that healing is always possible. Hope - not necessarily for physical cure, but for the ability to live a full and meaningful life - is an essential part of healing and of wholeness.
That shift in world view, or outlook, from despair toward hope, is foundational to healing the whole. It may also be an essential shift in improving basic medical care. I had a fascinating conversation with a York University professor recently. She works on safety and medical errors. We quickly began to focus on the complex environments in which we both work, and the need for adaptive leadership rather than technical fixes. Those technical fixes in hospital safety don't seem to have produced the kinds of results that were expected - in many contexts, error rates have not changed in 10 years. What's needed is a shift in focus from the very local to the more global - in the same way that healing a patient is more likely if one addresses the whole person. Certainly some habits and behaviors need changing - hand-washing, use of checklists in the operating room, electronic charting - but it appears that even when people know what's needed, local cultures militate against those changes. We talked about the difference in the culture between pilots and the medical community. It's fascinating to recognize that cockpit checklists work, and are well-used, particularly in parts of the aviation industry that are multiply redundant and have training or inculturation systems that expect compliance.
Why the difference? Is there resistance to a team approach in medicine? Is it a far more complex environment? Or is there a different kind of need to shift the focus to the larger goal? Is there investment in a larger-picture cultural change that insists on healing rather than fixing? Is there sufficient time for practitioners, rather than only managers, to think proactively and strategically? Significant strides in aviation safety were made when regulators began to look at accidents systemically. The NTSB investigates all aircraft incidents and accidents, reports publicly, studies the results over time, and as a result the FAA changes its safety education for pilots. Why the differences in system-wide reporting and accountability between aviation and medicine?
I don't have the answer, but it is an intriguing problem, that may hold some of the seeds needed for more global kinds of healing.
As challenging as it is to build a healthier hospital system across this nation, global wholeness - a healed world - can be even more intimidating to the psyche and spirit of healers. The need and the diagnosis are overwhelming and the response has too often been spiritual or developmental paralysis. We observed World AIDS Day on Wednesday, and 30 years into this pandemic, there are 33 million living with HIV, 2.5 million new infections a year, and significantly underfunded prevention and drug treatment efforts.
Yet even in the face of wretched international health statistics, there is a great deal of hope. We have begun to think globally about health, not just about individual diseases, but about many of the complicating and contributing factors in health. The Millennium Development Goals represent a shift toward global goal-setting and addressing underlying factors. Promulgated by the UN, those goals have been engaged and promoted by faith communities and governments.
The MDGs grew out of economic modeling and sociological and epidemiological studies toward the end of the last century. Progress in addressing the worst of the world's sickness and poverty was being made in some areas, yet there was little coherent focus on particular issues, and little ongoing attempt to measure input and response. After economic projections showed that a relatively small contribution by the developed nations of the world would likely go a long way toward healing some of that dis-ease, people of faith began to rally support. A partnership between developed and developing nations at the turn of the millennium committed the wealthy to dedicate a specific portion of their national economic output to targeted foreign aid and the developing nations to build their capacity to receive such aid in accountable ways. That charter for healing challenged all parties to measure and benchmark our collective progress toward specific goals in a short 15 years. We're less than 5 years away from that date, and while we've seen some progress, we have a long way to go.
The MDGs set out eight focused areas of progress in healing, and while they apply specifically to developing nations, equivalent conditions exist in parts of the developed world: our inner cities, Native American reservations, poor and depopulating rural areas. Learnings from sphere are often translatable to other contexts.
The MDGs focus on healing the worst of global poverty, through major reductions in hunger, preventable disease, child and maternal mortality; by improving the lot of women; ensuring general access to primary education, sanitation, potable water, and developing partnerships for sustainable development.
We're making progress, and the overall rate of poverty will likely fall to about 15%, or 900 million by 2015, from 1.4 billion today.
Basic education is an essential tool. More children are going to school, particularly in the poorest countries, yet poor girls in almost all developing nations have less access to education than do boys, and rural children are twice as likely to be out of school as those in urban areas. A primary education cuts the likelihood of contracting HIV by half. Lack of access to education for girls perpetuates high adolescent birth rates and high rates of maternal and child mortality.
That peripartum mortality is slowly being alleviated by improved access to trained health workers, and child mortality is falling as well. Yet neither goal is on track to be met by 2015. More than one-third of childhood mortality is the result of malnutrition. A quarter of children in the developing world are underweight, even though there has been progress since 1990.
Empowering women improves the lives of whole communities. Around the globe, women still do more of the labor, and receive less income, than men. Women have less access to capital, and globally, own only 1% of property. Fewer women than men have access to senior-level or political positions, though there is slow improvement. Healing requires changed power dynamics - as anyone who's studied the epidemiology of AIDS can attest.
Treating preventable disease, especially AIDS, TB, and malaria, is pretty doable, with enough money. As a global community, we spend about a quarter of what is necessary to treat and prevent AIDS, and the outlook is not encouraging. Even though the infection rate is declining, the portion of HIV positive persons in treatment is not keeping pace with new infections, and the global economic situation means it is unlikely to in the near future. We are making progress on malaria, with rapidly growing rates of bed net use in some parts of sub-Saharan Africa. It appears that the world-wide goal for tuberculosis reduction has been met, though it's still the next major killer after AIDS (1.8 million).
Some of the healing work is about basic hygiene. Most regions of the world are on target to meet their potable water goals, but nearly half the developing world's population lack adequate sanitation, and those numbers are growing. Slum conditions are slowly improving, but improvement is not keeping pace with the rising number of people living there, and violent conflict is a significant contributor.
International aid for all of this work has increased, though not proportionally in Africa. In total, it's still less than half of what developed nations committed in 2000.
These global statistics are striking, graphic, and challenging. There are similar realities here in the US, and in Cook County. We can talk about those challenges as systemic injustices or as epidemiological realities. The reality is that only a partnership of many healers can begin to address them.
There is an element we've not discusses at any length - violence. The death and destruction in Our Lady of Health/Salvation in Baghdad shares roots with the epidemic of fistulas (both as a result of rape and the lack of access to skilled health workers during childbirth) in many war-torn parts of Africa, and with suicide rates on Native American reservations and homicides in Cook County. Healers must attend to that violence. It's a symptom of grievous dis-ease, and it's only going to be addressed by shifting our gaze to the level of communities.
CeaseFire started here in Chicago, connected to the University of Illinois. It's treating gang violence as an epidemic, teaching children and young people not to pass on violent behavior, and improving resistance to violence in the wider community. It connects several kinds of healers and healing: the criminal justice system, faith leaders, public education, work with youth, and hospital-based intervention. It teaches healing techniques like conflict mediation, interrupting violence, and non-violent responses.
We are beginning to see remarkable partnerships between philanthropists, medical practitioners, communities of faith, entrepreneurs, the academy, and governments to heal the world. It's going to take many of us, working together, to begin to bring a vision of a healed world to reality, yet our own health and survival ultimately depends on our willingness to engage healing in larger, even cosmic, contexts.
[Taken with permission from the website of The Episcopal Church.]