Berkley Center

Background: Guatemala’s development challenges include weak healthcare systems and high inequality. Many uncounted, foreign missions (most from the U.S.) visit Guatemala full of good intentions but their lasting impact is unknown and not researched. The overall mission pattern can undermine local capacity and even cause harm. Dr. Michael Soderling came to appreciate pitfalls in Christian mission work during 11 years spent in Guatemala. His experience there inspired an understanding of public health needs in “majority world” settings that translates today into teaching, writing, and research work. The context for this conversation on August 25, 2015 with Katherine Marshall (by Skype) was preparatory work for a Berkley Center/WFDD research program on religion and development in Guatemala, but it addressed broader issues of faith and health as well. Dr. Soderling brings a deep appreciation for what he terms wholistic care, arguing that even the weakest public health system must take cultural dimensions into account. His work also links the need for rigorous research with a pragmatic focus on best practice, geared to what people working at the community level need to know and can apply in practice.

What took you to Guatemala? What were highlights of your experience there?

After years of practicing in the U.S. in obstetrics and gynecology, I felt called to give up my practice and move, with my family, to Guatemala. I knew that it would take some time to learn the language and acclimatize myself to the environment so I did not immediately take on any structured work. During that interim period I worked with some mission teams, as a doctor was always welcome. I realized quickly that the model was deeply flawed. People, including doctors, often came, with much zeal to do good but with little to no perspective on the country. Health workers in a community that a mission planned to visit would simply go on vacation, sensing that their inputs would be sidelined. Thus there was no learning and capacity building. The attitude of the mission teams and their local partners tended to be that the government was corrupt so there was no point working with it. Their vision and objectives were strictly short term. Among the problems was a complete lack of any systems for follow up. One story illustrates the point. I was working with a team of doctors and we delivered twins in a rural village. There were six western-trained physicians and we were proud of what we had done. The babies were healthy though underweight. We left. A year later we revisited the village. The parents came to the clinic with one of the twins, who was severely malnourished. The other twin had already died. I realized that we were not doing what was needed and began to reflect on what we, as westerners, could and should do in such situations. How could we best contribute?

Did you practice medicine in Guatemala?

When I left the U.S. I stopped practicing medicine, though I am still licensed. I went to Guatemala with no firm plan; I simply knew that it was where we were supposed to go. I also knew that it would be easy to find something to do. Guatemala’s regulations for physicians coming from the U.S. or other places are pretty extensive. You have to take a test that is pretty much impossible to pass [because it was so complex], or sign up to work for one year with the Guatemalan government health system, anywhere they send you. With three kids that was pretty well impossible so I did not pursue the option. We lived in the community of San Cristobal, on the outskirts of Guatemala City. Many missionaries settle there, in part because there is a good school for their own children. In practice, a physician was always welcome. I did not need to go looking for things to do; people came to me and I was called on often.

How far are the foreign Christian missions coordinated?

Not at all. As far as I know there are no effective controls on mission trips or system of monitoring them. There are supposed to be such systems, in theory, and a mission group can register. It is not difficult for a foreign physician to get a temporary license. However, most groups do not go through that process. A majority of missions are connected with sending agencies, but some are just sent by their church group. It is not at all uncommon for a U.S. church to have a Guatemalan church connection (and vice versa, of course). And mission groups like to have doctors come as part of the group. Most church leaders in Guatemala are not particularly interested in connecting with the government. As I worked with missions I realized that any medical doctor will be welcomed. The assumption is that you have lots of money and that you can bring resources. The first thought when a foreign mission is concerned is that this can be a rich connection—we can get something from them, they will build something, etc. So a mission team can go anywhere and do pretty much anything. Even if laws are in place they are not enforced and are ignored. I suspect that that has not changed since I left. I often say, joking but not really joking, that the biggest curse for a poor country is to be located near the United States. The closer they are the easier it is for well-meaning people to get to a poor country and the worse off the country will be. The short term good links to more damage in the long term because the visitors support the structures there that keep things the way they are. The reality is that doing good has to have far more than good intentions and a short time horizon.

Can you talk of the turning point in 2004 when you heard Dr. Dan Fountain speak?

In 2004 I met Dr. Dan Fountain, who was lecturing at a workshop in Bristol, Tennessee. He had worked in the Democratic Republic of the Congo from 1961 to '96, and was responsible for designing the health zone system there. He was with Sanru’s rural health program. His message about what he had come to think of as important in health care inspired me and caused me to do a 180 degree turn in my thinking. He became my mentor. The core idea was that the role of westerners must be less as doers, far more as enablers and capacity builders. I concluded that in Guatemala (and elsewhere) I needed to look for people from the country and come alongside them. One such person was Dr. Erick Estrada. I worked with him to create an institution called Transformational Health Guatemala (Salud que Transforma), a legally established Guatemalan association whose purpose is to network Christians working in the area of healthcare and community development. With it, we run two community health and development projects. It works in various parts of Guatemala.

You also helped to found a shelter for abused women. How did you become involved in that issue?

It quickly became obvious to me how women were treated and mistreated. They are, as in many parts of the world, seen as second class citizens. There are many femicides and female abuse is a big problem. Few were doing much to help so we co-founded Partnership in Women’s Ministry which runs El Refugio, a shelter in San Cristobal, that is managed by a Guatemalan. Women come there with their children, if they have them. They are often referred by the police or by some part of the government. The place is always full. We try to limit stays to a year but that does not always work. We work with the women to give them skills and hope that during their stay they will find what their gift or calling might be. There is lots of counseling; we have a psychologist, and social workers—a very wholistic approach. We set up a savings account for each woman when she arrives. There is a small business enterprise; the women make jewelry and other things that are sold in the U.S. and the women have a share of the profits deposited in their bank account. A few years back (perhaps in 2010) the government became concerned about the problems of abuse of women so there was a big push to try to overcome them. There were hotlines established as well as some centers. It was a complete failure, and as far as I know there is not much going on now.

How did you get involved in education?

A friend coaxed me to take a look at a small Christian school (Luz y Vida), way up in the northwest of Cuchumatanes mountains, in the department of Quiche. It was an area where the civil war was especially brutal. The school was built in the late 1980s but it was not used as a school until 2003. I helped them with their organizational development and to connect with donors. It is now in its seventh year. I also served on the school board of the Christian Academy of Guatemala.

How did you come to understand the religious landscape in Guatemala?

We were not working through a church per se nor was I associated with a particular denomination. Rather, I worked with and through organizations that were Christian but not affiliated directly with any religious group. We did not have much to do with the Catholic Church. In this way I was able to come to a very good understanding of the religious landscape of Guatemala. In general the church in Guatemala is very divided and the religious scene presents quite a mixture. I would call it a mess. The way the church is functioning overall is not very beneficial to overall development agenda. A lot of that is our own fault as Christians. The catholics want nothing to do with evangelicals and vice versa. I don't know how many denominations there are, probably 400-plus. There is a lot of infighting, squabbles over territory and about Kingdom visions. There is a lot of prosperity gospel. There is very little coordination of activities for the benefit of poor and not many are thinking in an integrated way even about issues of justice that are important to the church. The separate initiatives and things that churches involve themselves with are not very wholistic. There are some exceptions, but most pastors, especially in small rural communities, are simply trying to survive.

Are churches much involved in healthcare? There seems to be far less engagement than in Anglophone Africa.

No, not much. There is indeed a big difference with Africa. The difference has a lot to do with the dominance of the Catholic church in Latin America. The missionary endeavors were very different. Spain basically looked at Latin America as a cash cow, a source of gold and other riches that would enrich Spain. It was completely different in Africa. The Catholic Church was far less involved in Latin America in health care. There are a few faith run hospitals and some have some Catholic connection. El Pilar hospital in Guatemala City is one of the most respected and I believe it is still owned, at least in part, by the Spanish Government. There are also mission hospitals, for example in the Petén Peninsula, in Chichicastenango, Nebaj, and a few in Guatemala City are supposedly mission hospitals. There was an effort to create a Christian hospital association, but there was not much interest. The different clinics and hospitals tend to do their own thing.

You focus now very much on global health, broadly. How did you find the understanding in Guatemala of what that involved—involving the community, for example?

There was not much real interest there, on the part of those doing short term medical missions, in public health (meaning the health of the population, as well as broader health interventions in the community). But what we teach and promote now is really outside the norm even of what counts generally as public health; my definition of public health would be quite different from, say, that of Doctors Without Borders. The approach that I learned mainly from Dan Fountain and from my own experience has more to do with transformation. Dan Fountain died two years ago, and I still teach the class that I attended where I first heard him speak. What we teach is basically what the Bible teaches about health. It comes down to shalom, which we translate as peace. But our understanding of what this rich Hebrew word means is limited, often to simply the absence of conflict. It is rather a much richer word that is linked to an understanding of worldview. It is about basic assumptions and values that guide the choices people make. One of the frustrations Dan Fountain had was the limited understanding of what community health involves and how many people implement oversimplified ways to overcome health problems in the world. Our view is that the majority of the challenge is helping people overcome their world view.

What does the change in worldview involve?

Most who live in what we call the majority world—formerly referred to as the third world—function from the perspective of a fatalistic view. “We’ve been poor forever, we’re poor now, and we’ll probably always be poor and there is nothing we can do about it. The Gods determine our fate, or there is an arbitrary superior being who capriciously decides our fate. We can’t help what happens.” This worldview does exist in the Christian church as well. Such views have a significant impact on the health of people and the values that they ascribe to. And the values within a given culture have a significant impact on their health. I would certainly not argue with the view of those who argue that the big problem is broken systems, corruption, lack of education, and all the multiple factors that weaken health systems. And I am not trying to minimize complexity. But what is usually left out in the secular humanist faith system when trying to solve the world's problems is the importance of culture. These actors are never able to give culture the attention it deserves. Yes, dealing with culture is super messy and it is very difficult to do. The anthropologists have cautioned us to keep our hands off culture; let people stay the way they are seems to be their mantra. That is ridiculous, because cultures of course do change. The question is who and what will have the most impact on that change. That is what we are trying to do with what we teach.

Why did you leave Guatemala and return to the United States?

The impetus for my return was to work with a new medical school in North Carolina that was just getting underway. It was advertised as a Christian medical school, and Dan Fountain and another physician and I were engaged to assist in making this a truly Christian medical school which prepared students interested in long term cross-cultural service. But then Dan Fountain became ill and passed away about two years ago. The school did not work out as intended so after a year and a half I left and moved to California. There I took on the leadership of Center for Health in Mission. We are working to develop the Fountain School for Community and Global Health. The idea is that this will serve not only westerners who seek to serve in healthcare missions but also people from the majority world, with most teaching at a distance so students can stay in their workplace and teaching will not be out of context. Students have mentors from the school and do visit from time to time. Many are already serving in NGOs. At the William Carey International University we have about 60 Ph.D. students and 40 to 50 in the master's program. The largest group comes from African countries but there is a wide variety. The degree conferred is in international development. Our idea is to take the material that Dan Fountain taught and expand it as the core of a masters program. We call it a master's in intercultural health studies. This could also take the form of simply an emphasis in the WCIU M.A. program already mentioned (so the degree would be an M.A. in international development with an emphasis in global health).

How do you maintain your Guatemala connection?

I do stay in touch, though I have not been there for more than a year. The projects I worked on are continuing with Guatemalan leaders. I still serve on several boards.

You launched the Christian Journal for Global Health at a CCIH conference a couple of years ago. How is it progressing? And what are your next priorities?

I think it’s a terrific journal! We have a tremendous editorial board and there have been three issues. It fills an important gap, a niche, reflecting the concerns and work of those who are doing health outreach in the name of the Christian church. They (dedicated Christian healthcare professionals) are doing a lot of work in very difficult places, notably in Christian hospitals, but there is not a lot of research coming out around what they are doing. We hope we can get some students to fill these gaps, with final papers, theses, etc. And I have a lot of dreams! One of them is that I would like to see a global mapping project of Christian health work. There is ARHAP/IRHAP (African/International Religious Health Assets Program) and an initiative out of Colorado Springs. SANRU is involved. There are various issue networks and even some networking networks. There is a solid base of work to build on, for example in Emmanuel Hospital in India, the Christian Health Associations in Africa, and so on. A global mapping exercise could start there. But there are still many gaps in knowledge and a simple mapping locating different efforts does not help much. It just tells you it is there. Further, some do not want this information to be available because their work is sensitive or they are in conflict zones. But the technology is making such efforts easier. We also have a dream of building an international Christian Hospital Association. An important gap is in what we call best practices in global health missions. Many groups and associations are talking about best practices, and it sounds good, but very few are writing about it. I am part of a group that includes Christian Association for International Health (CCIH), African Inland Mission (AIM), and Serving in Mission (SIM) are part of a group working in this area. We hope to define what we mean by best practice and build a form of template and a practical review system. The idea is that a best practice is a step down from a journal article but carefully prepared and appropriately vetted.

Can you give an example of what you might consider a best practice?

A friend in the Philippines who inherited a family hospital gave me one example. As the hospital grew, there was discussion of how to put in place suction needed in various procedures in the intensive care unit. It was someone from the mechanical unit who suggested taking a device used to inflate tires, reverse the suction, and adapt it for use. It worked and was super cheap. It was a local idea that came from within. There are many other examples of simple or not so simple practices developed out of need but not shared. Areas could be triple therapies, tuberculosis care, etc. What comes to mind most vividly is hospital administration where there is a great need for innovations that can be very simple. An example from an African country is a situation where the officer who controlled the cash box was under great pressure because of the culture to give money to family members if they asked for it. The solution was to have two keys, and thus two hands holding the keys whose owners were not related.

What is your involvement with the Lausanne Movement?

There is growing interest in addressing health issues (among others) and there are 36 issue networks. The Lausanne Movement started in 1974 and developed over the course of three global meetings, the most recent in Cape Town in 2010. I am a co-senior associate for the Health in Mission Issue Network. In some senses the idea is to build a network of networks, but above all to connect with influencers. That requires lots of emails, but there are also regional consultations, and we may hold a global consultation on health in mission. At a couple of levels down from a global consultation are what I call regional conversations. As an example, in December in Jakarta there will be a meeting at a Christian university there on Christian responses to global health issues. I hope to make this a Lausanne Health In Mission Regional Conversation and hope to get 20 to 25 local leaders together, to share ideas and best practices. A hope is that part of the conversation will focus on the church’s understanding of health in Indonesia. Then there are regional conversations and meetings (the Lausanne Movement has twelve regions globally). It is really a global movement, trying to bring people together. In parallel there is the World Evangelical Alliance, somewhat similar though less involved in health issues, and the World Council of Churches. Often they do not see eye to eye but a recent meeting sought to establish common ground.

You have a broad view of faith. How would you characterize it?

I would say, and I say often, that in truth there is not a person on earth who does not function from a faith system. Those who are part of a secular humanist faith system, even if they do not believe in a creator or superior being, have faith in something. It may be that they see a system that is inspired by the goodness of man, science, or reason. It is a religious system, even if that is not the classic system with a higher power or deity. It is just as much a system of faith as a religious system. It has its idols, doctrine, proselytizers, and history to explain what has happened. World experience does suggest that leaving faith out of equation leads to bad things.

Based on your 11 years in Guatemala, what are areas where you might suggest that we (the Berkley Center and WFDD) concentrate in our research?

In general I have doubts about many research efforts that convene meetings where those who attend are those who are in power. You often will not hear the total truth about what is going on. I was recently at a meeting where a nurse who worked through a big organization put forth a plan to eliminate worms in all Guatemalan children with a regime based on giving and then repeating a dose with pills. It was the most ridiculous plan I had ever heard of. There was simply no awareness of the realities on the ground, in the trenches. I would love someone to research the impact of the short term medical teams. Can anyone demonstrate positive long term impacts? These short term teams rarely have much interest in their long term effects. They want to keep the teams going, bring in money, and get people (the missions) fired up. In some circumstances they seem almost criminal, akin to practicing without a license. Because they are literally short term groups, nobody has any inkling of what happens afterwards and whether they are doing any good. Is the medical outreach making any difference? Also what is the experience and impact of long term projects, for example the little mission hospitals. How are they connected with the local system, with the government? Does the government even care or are we giving the government an out, releasing them of responsibility? It would be good to know more about how this works in practice. My own interest is in developing further a systems thinking approach, along the lines of what Peter Senge from MIT calls the fifth discipline. More critical thinking is especially important to global health.