A Discussion with Frank Dimmock about His Work in Africa in Christian Health Ministry

With: Frank Dimmock Berkley Center Profile

August 31, 2009

Background: Frank Dimmock is a health consultant focused on southern and eastern Africa working with the Christian Health Association, currently from Lesotho. With an MPH degree in epidemiology and tropical medicine, he has directed his work towards health issues and vulnerable children. In this discussion, Dimmock talks about the development of Christian health facilities and his path to working to support their evolving roles in contemporary Africa. He also speaks about how faith inspired him to work in Africa and how development work in Africa, based on his own experiences in Lesotho, can be specifically geared toward countering malnutrition and ensuring maternal health.

Can we start at the beginning? How did you come to be so much involved in health issues for Africa? And how did your religious background contribute to your career path?

Soon after I finished college, in 1979, I became very interested in hunger and nutrition in Africa.

I had a great interest in missionary work from an early stage. My grandparents had been missionaries in China. I had also read books about Africa and the Congo. I was inspired by stories of malnutrition in Africa, for example by Dr. Richard Brown. I had studied while I was at college to be a medical doctor, but thought I was not ready to make that commitment. The idea of volunteering for my church in Africa for a year was attractive. My dad was a minister, so the step seemed natural. I contacted the denomination offices and was assigned to the Congo. A few weeks later, with a passport and full of shots, I was in Mbuji-Mayi, central Congo (Zaire), working in a health center that had a nutrition rehabilitation program as part of its work.

It was a big step. I spoke no French at the time, only German, was homesick, and got malaria. But I stuck it out and spent nearly two years there. As part of my work, I conducted a community survey that allowed me to diagnose nutrition issues, which were especially serious for children. Poverty was widespread and its impact dramatic. So my interest and commitment deepened.

When I returned home I decided to study public health rather than go to medical school. I finished my master's degree at Tulane, then started on a doctorate at the University of North Carolina, Chapel Hill.

In the midst of my studies, the church asked me to return to the Congo because of an emergency situation. There was terrible poverty and malnutrition, which I knew well. It was what I was called to do, and I felt my faith calling me to Africa and to public health.

After another year in Mbuji-mayi, I returned to the United States to get married. I had in fact, when I was in the Congo, back in 1979, lived in the very house where my future wife had grown up. She came from a family of missionaries in the Congo. I had heard about her while I was there, then met her in the United States in graduate school four years later.

We moved then to Lesotho, where I worked with the Department of Community Health, based at the Scott Hospital. I took over from a Dutch doctor and directed a large community health program. It was a perfect arrangement, and we spent six years there. I was able to hand over the direction of the program to a qualified Mosotho.

Following a furlough in the United States, we moved back to Africa, this time to Malawi. We spent four years in the north, working with three hospitals and community health programs there. Then the two other Presbyterian synods wanted me to work on a broader basis so we moved centrally, to Lilongwe, where I engaged with all three synods. That was when I became more directly involved with the Christian Health Association of Malawi; I served on their board as vice chair.

It was during this period that I began to see the health challenges and issues at a broader level. I was involved in negotiations with the Ministry of Health and a wide range of partnership arrangements. I realized how vital the Christian health work was to the country and began an effort to document it. The government was beginning to ask questions: essentially, “show us." It was clear that the church health institutions did not have very good records; they simply did not see that as a central purpose of their ministry.

In 1997, the Presbyterian Church asked me to share my experiences with other partner churches in Kenya, Zambia, and Ethiopia. I began to travel to each country regularly and connected with Christian Health networks in each country.

When did you first become involved with ARHAP (African Religious Health Assets Program)?

In 2002, I was visiting the Carter Center in Atlanta and met Jim Cochrane and Gary Gunderson. We found a common interest, and I saw much value in the thinking which was giving birth then to ARHAP. Because of my involvement in Lesotho, Malawi, Kenya, and Zambia, we could see immediate relevance in an effort to document and align the arguments for supporting the Christian health systems that played a significant role in national health.

Mapping was a strong personal interest, something of a hobby. I see great potential in GIS and had participated in a Lesotho baseline study that involved extensive mapping. So I was involved in ARHAP from the start, working on the WHO study. I was part of the team that presented the results of that study at the Washington National Cathedral. Along the way, I got to know Ted Karpf, and I had actually introduced him to Gary Gunderson and prompted him to take on the Lesotho and Zambia study. When we presented our Lesotho maps, he found them exciting, saying immediately that he saw a strong need for this kind of information.

Many significant people joined the effort, and we were able to build partnerships around advocacy and were working to ensure that the faith-health community was at the table. We had as a goal to rationalize the health systems and to help ensure high standards across the complex parts of the system. That stimulated networking and encouraged transparency and accountability.

What do you see as the major surprises or key insights that came out of your own ARHAP work?

I was somewhat surprised and certainly thrilled by the attention given by the international community. It was an indication that advocacy efforts, supported by evidence, were paying off. We needed to continue this work, do more, and do it better.

What are the most pressing and immediate problems for Lesotho, to take a specific case?

Within health services, the immediate driver in Lesotho is the deficit financial situation of the Christian hospitals and the government health facilities. The government is providing financial subsidy and auditing Christian hospitals. The process of opening up the books, so that the government can examine revenues and expenditures, including donations, has changed the dynamics of partnership within the sector. In regards the health of the Basotho, clearly HIV and AIDS remains the greatest challenge.

What has changed that has led to the new agreement?

The financial situation became desperate enough. Many of the Christian hospitals came to the point of closure, facing the need to hand over facilities to the government. They hated the prospect of seeing quality deteriorate and saw that this was beginning to happen because of financial shortages. So the question was asked, if the government just realized the importance of these systems to the health of the population, would they not support them? That led to partnership discussions and an agreement.

This situation was not always the case. In the past the churches were able to finance the health facilities, through the 1980s and 1990s, from overseas church donors and well-wishers. But as time went on this became more and more difficult.

Why? Were health facilities more expensive? Donations harder to find?

Both were true. Delivering healthcare in rural areas became increasingly expensive. Many buildings and facilities have deteriorated and needed maintenance (particularly expensive since it was overdue) or reconstruction. In addition, many churches began to shift their patterns of funding overseas mission work. They moved increasingly towards designated funding, preferring not to have block grants for general operations. Supply of long-term mission personnel dropped sharply. Expenses like building maintenance and equipment repair were increasingly difficult to finance.

Do you see similarities in the systems in other countries, notably Kenya and Malawi?

There are both similarities and differences. The hospitals and clinics in both those countries were mission hospitals originally, built by foreign missionaries. They were rarely community hospitals, and support came from outside. After independence, there had to be a significant shift, so that they became church and community hospitals. Medical missionaries as such all but disappeared. Today, that era is pretty much history. So outside churches contribute less and less money. But there is a residual belief in ministries of health that the churches and church hospitals continue to receive generous support from overseas donors.

Is this true across different denominations?

Yes, the same kind of dynamic has taken place, in Lutheran, Anglican, and other communities. The effort and the aim is to ensure that these facilities are community enterprises, owned in a real sense by the communities.

The Catholic churches have not been as much affected, but there are signs of the same phenomenon. There tend to be more expatriate staff in the Catholic hospitals.

This is a difficult question, but can you provide some insights on the differences you see or might expect to see between hospitals or clinics run by churches and those by governments or private operators? And are there significant differences among the approaches you see among different denominations? Can you point to any particular centers of excellence that would be worth studying?

I worked as an administrator of a medium-sized church hospital in Lesotho for several years, and we asked staff and patients why they worked, or chose to attend, a mission hospital instead of a government one. The answer was often the desire for a holistic health service, including spiritual and compassionate healing. This response matched the mission statement of many church health facilities that aim to address needs of the whole person. We began each day with devotional services for all staff and in the wards for patients. It was an opportunity to refocus our attention to the mission and assignments of the day. Chaplaincy and psychosocial health are critical dimensions of healthcare, and not surprisingly, often the busiest services. In many church facilities, these services are also frequently extended to the community through home-based care, community integrated preschools, community-based rehabilitation, and through extension workers (often recruited and trained in local churches).

What would you see as particularly important measures to address child malnutrition?

Malnutrition (especially undernutrition) will continue to increase in many parts of the world, especially in urban slum areas. As urban populations increase rapidly, food supplies and fuel for cooking become scarce and expensive. This trend is already reflected in the health and nutritional status of children in cities. In Kinshasa, Democratic Republic of Congo, for example, there are 10.5 million people who must eat daily. Many of the new immigrants were used to collecting their food from gardens or smallholdings. Now they must rely largely on nearby markets that are subject to external forces and supply. It is critical that programs for urban gardening be expanded and infrastructure surrounding cities developed to continue to provide basic food security. We must continue to provide nutrition education, but without food security it is futile.

What are successful interventions to bring down maternal mortality?

Maternal health should be a priority global health focus. Safe motherhood clearly results in better family health. Maternal mortality is a benchmark indicator of quality of healthcare in general, and we obviously have much to do. Many women have been educated about safe pregnancy and birth, but often they are not the ones empowered to make critical decisions. Our education programs on maternal health must also reach men and others in the community who often act as gatekeepers or facilitate access to health facilities. They are also key to planning for their families. Secondly, providing skilled health workers at the community or clinic level is essential. Supporting them with equipment for safe deliveries and referral (communication and transport) can be lifesaving. There are places where clinics exist without trained staff for assisting with deliveries or complications. Training must be accelerated and qualified staff must be retained in rural facilities.

What effects are you seeing from the crisis?

There are many challenges in health across Africa. I guess I see both global (external) issues that must be addressed, as well as some local issues that can be dealt with. On the macro level, food security and sustainable energy sources must match population growth and migration trends. These are influenced by climate changes and market forces that lie beyond the awareness or control of the general population. Potable water and proper sanitation are key areas for disease prevention and good health. Both will become increasingly important in the future. Addressing health-related crises (e.g. disease outbreaks) will become increasingly challenging and costly. It is vital that resources directed to underlying causes balance those directed to putting out the fires. One effect that I see of the stresses within the health sector is a decline in numbers of candidates for training as health professionals (especially called to serve in rural, under-developed areas). What was once a calling to serve and a prestigious vocation has become too risky, with implications for family and personal health that are too costly.

Progress is being made in some areas of public health, while in other areas the challenges are growing. As a public health worker in Africa for the past 30 years, I am most concerned now about the nutritional status of women and children and the access to essential maternal and child health services in rural and urban areas. It is the lack of access to basic health, education and social services, and availability of economic employment that has pushed many rural dwellers to the urban periphery. Efforts in rural development during the 1980s and early 1990s were insufficient and ineffective. Now we're witnessing the consequences with 5 plus percent urban growth rates and related social and security concerns in cities.

You have mentioned a myriad of challenges you face in your work. What keeps you from becoming overwhelmed?

My primary interest as a public health professional is in promoting health. My primary role as a Christian mission worker is sharing and spreading my faith. There is a natural intersection of the two, and that point provides inspiration and peace. My wife and family have also been incredibly supportive and understanding.

My main research interest for many years has been the development of resilience, especially among children. I have observed that resilience to life crises of all types is built on hope, and that hope is often founded on, and strengthened by, faith. That faith may evolve from personal knowledge and experience, or in the case of many children, may develop from the faith of a significant adult nearby. There are many, many African friends and colleagues in mission service who also inspire me and keep me balanced.

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