The Cost and the Joys of Serving the Least of These
I am to speak today on “The Cost and Joys of Serving the Least of These,” but first, I want to retrace with you my history with CCHF. I came from Jamaica - to Madison, Wisconsin in the early eighties as a new wife. Elward, my husband, was the Director of Black Campus Ministry for InterVarsity Christian Fellowship. I had wrestled with the Lord on this move as, in my economy,there was a much greater need for physicians in the two-thirds world than in the USA. I had always had a sense of calling to work with those most in need and, after the death of my first husband, had become very immersed in my work both at the University Hospital of the West Indies in Kingston and as a volunteer physician at a wholistic clinic that was part of the Bethel Baptist Healing Ministry.
The move prompted me on a fresh search for identity. I wondered who I was; I wondered about my relevancy in the USA; I wondered why there was so much here, why everyone seemed to talk so much about the things that they wanted; I wondered whether there were any persons here who had a calling to serve anyone else but themselves. My husband, probably aware of my disorientation and having been asked to serve on the board of the fledgling Christian Community Health Fellowship, suggested that his wife be asked instead, since she was a medical doctor and had similar values.
To me at that time, CCHF was a breath of fresh air! Early board meetings focused on the scope of the mission: to be a clearing house for information about health care for the poor; to offer models of ministry in urban and rural areas; to assist starting ministries; to provide places for students in health care to see the gospel for health care to the poor lived out. Those early board meetings were pioneering ones. There were plenty of apples and oranges and peanut butter sandwiches in barely heated church halls and school rooms.
Overwhelmed by the wealth, the choices, the materialism that I saw in America, coming from Jamaica where the pediatric wards were still wrestling with diarrhea and malnutrition, it was a treat to be among these generous-hearted and sincere people who were grappling with the realities of poverty in the richest country in the world.
This was no flight of fancy of rich white kids assuaging guilt; this was a group of people who had dug their heels in for the long haul based on their willingness and call to serve Jesus Christ while serving the health needs of the least of these. It was a privilege to have been a board member in those early days. I cannot fathom how as an ingénue, a nouveau arrive, I found any voice to input ideas, overwhelmed as I was with the whole scope of my new country, new culture and new role.Perhaps it was out of my own adjustment to the barriers of race in America, coming from the more creolized culture of the Caribbean, from my experience of the possibility of unity in diversity, that I was able to speak on serving Christ across racial and cultural lines. I remember my first plenary given at a CCHF conference. My title was on “The Dividing Wall of Hostility: Crossing Culture Lines.” I spoke about how, when getting to know a people group, we must first learn their history, their cultural journey. Then we must pray for the Spirit of Pentecost to assist us in building friendships across racial and cultural lines, a process which involves our willingness to make mistakes, tread on toes, risk rejection and experience displaced anger. Furthermore we may have to sacrifice some of our own cultural sacred icons in order to bridge the gaps to another culture. At the end of my talk, I remember asking for questions and then experiencing a dead silence. There were none. Interpreting the silence as a failure to communicate, I turned to Dave Caes and asked him what he thought about the talk and the silence. He said, “Dawn you said some pretty heavy things; people are silent because they are thinking about what you said. They haven’t had time to formulate questions.”
My practice as a health care professional has largely been in secular settings; in fact it vilas exclusively for the first twenty-four years in academic teaching hospitals. As I thought about my patients at the University Hospital in Kingston, Jamaica, at St George’s Hospital, London, at the University of Wisconsin Hospital and Clinics, in Madison, and at Grady Hospital in Atlanta, I realize that the majority of these patients came from poorer families.
In the early nineties I began to feel a restlessness with disease-oriented medicine. I wanted to interact with patients and families in community settings; I wanted to prevent some of the unnecessary hospitalizations; I wanted to develop better skills in interpersonal communication with children and families; to practice early behavioral interventions with families; and wanted to improve access to care for persons of different ethnicities and cultures.
When an opportunity came up to start a new Grady Neighborhood Health Center in the Buford Highway of Atlanta, the most culturally diverse region of the state, I jumped at it. Two experiences converged to make this an ideal move for me at this time. First, I had for four years successfully run a month-long training for pediatric residents and staff, on cultural diversity and health care with a multicultural, interdisciplinary team from pediatrics, social work, public health, and ethics, and was excited about the opportunity to practice some of the intercultural skills I had learned. Second, I was in the process of training as a facilitator of interpersonal communication in healthcare with the American Academy on Physician and Patient, now renamed the American Academy on Communication in Health Care. This organization, which involves physicians from some of the most prestigious medical schools in the country, teaches physicians and health professionals through experiential learning, self reflection and active listening techniques thatin being transparent and congruent and speaking from the “I” perspective, we can better understand ourselves and communicate more effectively with our patients.
The clinic: Our small provider team, along with our very diverse front desk staff, which included a Vietnamese, Korean and Hispanic receptionist, would sit at lunch each day and trade lunches, jokes, and stories about health care and parenting in each other’s cultures. We shared our different faiths, Christian, Muslim, Jewish, and we got to know the various ethnic community leaders and had some of them speak at our lunchtime gatherings.
The clinic has grown—we have had three medical directors since my initial appointment, all of whom still work in the clinic. We now have five family physicians, one internist, myself as the pediatrician, a pediatric nurse practitioner, and three OB midlevels with many more nurses,and medical assistants. The foreign-born percentages in the clinic have changed from being 40% Hispanic, 15% Vietnamese, and 10% Korean, to about 60% Hispanic, 10% South Asian, (principally Bengali), 10% African, and a smattering of other cultures, Chinese, Indonesia and Nepal. Applied learning from this: multicultural clinics will change their composition as different immigration groups come and go up the SES ladder. Clinics need to change to accommodate these new populations.
You ask: “But how do you practice as a Christian in this setting?”
When I came to Grady, I was asked: “Well which M are you: Marxist, Messianic, or Mad?” Grady was and is the safety net hospital of Atlanta—the hospital of the homeless, of the prisoners, of the gunshot wounds. It has the only Level 1 Trauma Center for the state, the only HIV clinic, the only burn unit. It was the black hospital; now the Hispanic influx is changing the obstetric floors to black and brown. It is also strapped for funds and is the object of daily news accounts that see Grady as closing, incompetent, in constant debt and unsustainable in it present mode of operation.
Health care in America is a tale of two cities: one wealthy, at the cutting edge ofinnovative technology, making incredible advances in cancer treatment and manufacturing more and more pharmaceutical products to alleviate every possible complaint; and one striving to give basic primary care, motivate patients to make important behavioral changes in diet and lifestyle, keep regular doctor’s appointments as well as their jobs, keep up with their children’s immunizations as well as their homework, and pay for three out of ten of the medicines prescribed by their physician.
This sarne great country, according to a publication on“The State of Children and Families 2007,” by the Center for Family Policy and Research, when compared with other industrialized nations, stands first in gross domestic product, first in the number of millionaires and billionaires, first in health technology and first in defense expenditure. While this same great country ranks 12th in living standards among our poorest one-fifth, 13th in the gap between rich and poor, in our efforts to lift children out of poverty, 22nd in the low birth weight rates, 25th in infant mortality and last in protecting children from gun violence.
This country needs more clinics that serve the underserved, needs more visiting nurses, needs more safe places for children in inner cities to play, needs healthier food in school cafeterias, more communities that function like communities, needs smaller neighborhood schools, the list goes on. The precarious state of Grady Hospital, where I have worked for the past 20 years, is a hot daily item in the Atlanta journal and Constitution. The report of the last set of consultants from a large NY firm hired by the County Authority that oversees the hospital has cited the neighborhood health clinic where I work as a financial risk because, even though we have the largest cash collections, we have the largest percent of uninsured patients.
A year ago, Emory University, my employer for the past 20 years, withdrew financial support of the physicians in the clinic, saying that we did not really fit the mission of the university, and besides they needed to find areas to reduce the over $40 million that Grady owed them. Also teaching students and elective residents did not bring in any money from graduate resident education so they needed to let us go.
So job security-wise, I stand this morning before you on very shaky ground. The topic which I chose to speak on is the very substance of which I live daily, the ground on which I walk. It has been difficult to distance myself enough to have objectivity, but as I prepared I wasn’t sure that objectivity was desired. For me, this is more like talking out of the feelings aroused by:
- a weary Eritrean mother bringing her children to the clinic for the third time, and finding out that the Medicaid has still not been reinstated, worrying because she doesn’t have the $100 the clinic receptionist asks her to pay for the children to be seen;
- by the panic in the voice of a Honduran mother whose son fractured his elbow playing soccer, had it casted in the ER but cannot find an orthopedic surgeon to follow up with because none of them take her kind of Medicaid;
- or the sadness of a mother’s eyes when she realizes that she cannot go home to Guatemala to see her sick mother because she probably would not be allowed back into the country and she has two children born here who are therefore citizens.
The heart of my message is “The Cost and Joys of Serving the Least of These.” For me the least of these are my children, dearly beloved, of all hues, shapes and sizes, from Mexico, Guatemala, Honduras, Nicaragua, the Dominican Republic, Ethiopia, Eritrea, Ivory Coast, Liberia, Ghana, Bangladesh, India, Nepal, Jamaica, Haiti, and of course, the USA. I feel uniquely privileged to be la doctora de Jose Manuel, the pediatra de Jaylin or Coral, the doctor for Shanya, Mohammed, or Daniel. I take special pleasure in the fact that all I have learned in 30 years as a pediatrician, all my training in interpersonal communication and intercultural communication, is pressed into service for the health supervision, diagnosis, education, advocacy, and partnership with parents and the clinic team, in raising healthy children at the North Dekalb Grady Clinic in Chamblee, Georgia.But what difference does it make that I am a Christian? My colleagues who are of various faiths believe in our mission as much as I do. How would anyone see the difference?
Years ago, I went to volunteer at an evening clinic at a church in Jamaica. I asked myself the same question then. What am I going to do differently here from what I do at the University teaching hospital all day? Isn’t it the Christ in me that makes the difference? Why do we talk about secular practice and Christian practice? Grumbling and regretting the day that I had agreed to work at this clinic, feeling tired and weary, I went into the clinic where I was cheerfully greeted by the triage nurse. She said, “I have one patient for you.” I thought, “I hope it isn’t a little old lady; they always find something to complain about even when they’re fine.”
Sure enough it was. She had pains all over her head to her foot. I did a thorough examination and found no cause for her pains; probably a little arthritis. I said, “You could take some Motrin.” And then I heard the voice: It came from inside my head, a steady calm gentle voice, “But do you love her?” Somewhat perplexed, I tried to shake my head to try to clear it, and the voice spoke again, “But Dawn, do you love her?” I was suddenly aware of the woman’s voice; she was saying something about her son. I said to her, “Tell me about your son.” She began to share a lot about her son, his hanging out with the wrong crowd, his coming in late, his failure to get and keep a job. She said, “Doctor I am so worried about him.” I offered to pray for her son, right then. In this clinic there were prayer partners in the floor above the clinic, there were counselors in the room beside but I felt compelled to pray for her myself.
Two weeks later, I was on my way to the clinic, tired and weary, wondering why I continued to go. As I got in, greeted by the cheery nurse, I saw the little old lady. She came in looking different. I asked about her pains. Right away she stood up, “Oh doctor don’t ask about my pains, I want to tell you something, but first let me thank you for praying for me. My son, doctor, he got a job, he is coming home and he don’t keep those bad friends no more. Thank you for praying.” God surely answered.
The lesson I learned that day is that our God is concerned not just that we give excellent care but, like the writer of 1 Corinthians 13 says, that we do so in love. Love opened my eyes and ears to hear the spiritual need in that woman, love provided the ability to listen and recall what was said and then love offered to her the resources of heaven in my offering to pray for her.
I have never forgotten that lesson. The greatest gift I can give to my patients as a Christian doctor is to love them the way that Christ would—unconditionally, sacrificially and wholistically. Love gives me the capacity to listen, to care, to not give up on them, to continually seek for appropriate resources and solutions to their problems.
How do we incorporate this Christ Love into our practice? For me it has been the application of God’s truth to my identity, calling, work ethic and anticipation of his reward.
Identity: When I first came to the US, I was a foreign medical graduate. I could not write a prescription, I was not able to practice. This after several years of practice, a fellowship and being head of my department. I felt disembodied. Who was I? Where was Dr. Swaby? Where were the telephone calls I was accustomed to receiving, the prescriptions to write, the advice to give to anxious mothers? If I couldn’t do that then who was I? What use was I to society? A wife surely, but was that enough? Galatians 3:23 spoke to me about who I was: I was a child of God; that was enough. I was his, created in his image, to do good works which he had appointed for me to do. And he would direct my paths if I committed my way to him. This is the basic identity of all Christians: We are children of God, and we are here to do what our Father has said that we must do. And his commandment is simple: Love him with all our heart, mind and strength and love our brother and sister as ourself. Finding our identity in Christ is good prevention for the discouragement, low self esteem, and feelings of powerlessness which cancome as we identify with our patients in the struggle to overcome obstructive bureaucracy.
We all have a calling on our lives. I knew I would be a pediatrician the moment I set foot on the pediatric wards of the UWI Mona, Jamaica. I also know that I am called to serve Jesus Christ, to make him known to all I meet and to be an ambassador and a reconciler. Working in a secular setting presents many opportunities to witness to our faith.
I guess because I am open about my faith I am frequently asked to pray at our clinic gatherings. After teaching a workshop on cultural competency I tried to change my prayer, to be less offensive to other faiths, but I found I could not but pray “In Jesus’ Name, Amen.” More than a habit, it is what I believe. I pray in his name.
I have had many precious opportunities to have conversations about faith and practice with non-Christian colleagues, Muslim, atheist, in which my main intent is to be true to what I believe and to demonstrate how my faith informs my practice and my life.
You never know what the Lord will do when you give him the opportunity. At a conference of the Academy on Physician and Patient mentioned earlier, I attended a workshop on meditation practices. The group was asked to repeatedly say the word “AH-OOM” together. After the exercise, the facilitator of the session asked me what was wrong as I had not entered into the meditation. I replied that I did not resonate with the word; I found it monotonous and uninspiring. The whole group graciously offered other words that would be more suitable and one person offered: “What about Alleluia?” “Oh yes,” I said, “I could always do Alleluia!” Thereupon, we all began singing “Alleluia.”
After 9/11, I decided that in giving an annual lecture on Cultural Diversity to the first year medical students at Emory, I should expand the definers of my cultural identity to include, in addition to boomer generation, married, Afro Caribbean, etc., that I was also a Radical Follower of Jesus Christ. I explained that by radical I meant at the root or core of my identity was my allegiance to Jesus Christ, that my own practice was affected deeply by my faith, and I was giving them permission to examine their own faith or spiritual beliefs and to determine how this would affect their practice as physicians.
The directive to be salt and light is one that we must take seriously when we think of our presence in clinic gatherings, hospital meetings, conferences, etc.
Our Work Ethic provides our witness to our Lord Jesus Christ. We must work hard, study hard, rightly divide the word of truth; we must practice with integrity and excellence; do justly, love mercy and walk humbly with our God; we must show mercy to the alien, the stranger, the widow, the single mother; we must follow our Master, take the gospel of the Kingdom of our Christ, the messianic call found in Luke’s gospel; and as his ambassadors, as his representatives and anointed with his spirit, to preach good news to the poor, to proclaim to the prisoners, recovery of sight for the blind, to release the oppressed, and proclaim the year of the Lord’s favor.
Opportunities to do this abound on a daily basis, of burn-out proportions, so we must do this in his strength, knowing that as his children, called to his purpose this is his work and doing it we will one day reap his reward,
The reward? His “Well done, thou good and faithful servant, who treated all those I sent to you with love, equity and imagination, who utilized the resources of Heaven as you prayed and interceded for them to your Father, who stood up to power with truth and were not ashamed to own your God as your guide and the only One whose anger you fear. Well done thou servant, who understood my greatest command to be to love me with all your heart mind soul and strength and your neighbor as yourself. Well done, you understood that there is sacrifice and challenge and hardship in my road to Heaven but like I told others before you, I am with you always, walking by your side, I will never leave you or forsake you and I will not allow anyone to pluck these little ones from your hand.”
E. Dawn Swaby-Ellis, MD. COG, Pediatrician, Called to Serve the Least of These, practices at the North Dekalb Grady Clinic in Chamblee, GA. She can be contacted at eswabye [at] emory [dot] edu.