Proud to be a Siphilile woman: Mission from the Margins

By Mats Målqvist

Every year, more than five million children die before their fifth birthday and almost 300,000 women perish in connection to pregnancy and childbirth. The reasons for these tragedies are not primarily medical, but a matter of priorities and values. Social and cultural structures maintain destructive power relations, leaving the most vulnerable at risk.

In 2012, Siphilile Maternal and Child Health was established in the Kingdom of eSwatini, recruiting and training Mentor Mothers to be peer supporters in their own disadvantaged communities. By addressing culture and gender roles, the Mentor Mothers set an example of how maternal and child health can be improved through empowerment, realizing that power lies in the powerless, and that change starts at the margin.

This book is an account of the process to develop and establish Siphilile, and an outside perspective on the Swazi society and culture. By trying to understand a different culture we can get a new perspective on our own, discovering the social structures that bind us.

• Language: English
• Publisher: Books on Demand
• Release date: Nov 12, 2019
• ISBN: 9789178516094

Mats Målqvist

Mats Målqvist is a Medical Doctor and Professor of Global Health at Uppsala University, Sweden. Between 2013 and 2016 he was the Project Manager/Executive Director for Siphilile Maternal and Child Health in Eswatini. His research aims to evaluate the implementation of interventions for improved maternal and child health and survival, with previous projects in Vietnam and Nepal. Mats Målqvist has a special research focus on inequity in health based on social determinants. His research is interdisciplinary, investigating drivers, mechanisms and outcomes of societal structures.

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(2016)

Preface

Still millions of children and hundreds of thousands of women die every year in connection to childbearing and childhood, despite simple and cheap measures to save them. History will look at it in one of two ways; either the judgement will be hard for letting this happen despite available resources and knowledge, a moral prerogative that was not fulfilled; or history will look only at the tremendous successes of quickly lowering the mortality rates, the so-called ‘child survival revolution’, possibly followed by a maternal survival ditto. The perspective history will take depends on our continued efforts, either we fulfil and accelerate progress or we will have a missed opportunity that will make judgement even harsher.

In 1999, on the advent of the new millennium, UN decided on a set of goals to inspire and focus on essential improvements for humanity: to reduce poverty and hunger, to prevent mothers and children from dying, to promote gender equality and secure education for all. These Millennium Development Goals (MDG) set high ambitions for improvement of the health and wellbeing of the world. Ending in 2015, it could be concluded that a lot of attention had been given to these areas mainly focusing on the vulnerable and voiceless. It contributed to an interest and attention on maternal and child health that maybe otherwise would not have been there, and the MDGs meant a lot for the acceleration of efforts to curb maternal and child mortality. The ambitious targets of reducing maternal mortality with three quarters from the level of 1990 and the child mortality with two thirds over the same period were not reached, but efforts were put on these otherwise neglected areas globally.

In 2012 the Swedish International Development Cooperation Agency (Sida) approached Church of Sweden asking if not the church and faith-based organisations could do more to contribute towards reaching MDGs 4 and 5, the targets on child and maternal health. This was part of an extra push by Sida to accelerate efforts towards the MDG end year of 2015. Church of Sweden was a trusted partner to Sida, channelling aid funds to more than 170 different partners around the world, acting in the global network of Alliance of Churches Together (ACT Alliance). The organisation also has a long history of development work and has recruited, trained and supplied health care staff to poor countries and settings around the world as part of its diaconal work. Mission hospitals and health care outreach have been integral parts of the missionary work of the church historically. But due to organisational adaptations and changed work methods, going away from directly initiating and managing project work abroad, Church of Sweden had lost much of its competency and connection to health work. With a new paradigm for how to engage in development work, starting in the 1990s, priorities were now set together with sister churches and partner organisations, and shifting the executive function to the local partners. The request from Sida to engage more actively in the MDG agenda came as an opportunity to revise and rejuvenate how Church of Sweden engaged in health.

Despite not sending Swedish health staff to Asia and Africa anymore, Church of Sweden had not been completely idle in terms of promoting good health internationally. Engaging with partners in different projects around the globe, Church of Sweden had been supporting initiatives and long-term commitments to improved health, in later years focusing on sexual and reproductive health. In southern Africa, much emphasis had been put on the HIV epidemic. One example of involvement in this area is the initiation of a Master’s program for theology students on HIV/AIDS and the churches’ role together with academic partners in South Africa. Another example is the long-standing support to Philani Maternal and Child Health and Nutrition Project in Cape Town. Philani is an organisation founded and led by Ingrid Le Roux, a Swedish medical doctor who came to South Africa in the 70s. She started working in the shanty towns outside Cape Town and founded the organisation that today is a well-established NGO with multiple activities and mandates. In the early 2000s Philani developed a community-based peer support model, when it became apparent that the work at the clinics did not suffice. Malnourished children who were treated at the clinic returned after some months in similar conditions as when they first came. The need to be present in the community and support and educate mothers and care givers on nutrition and healthy lifestyles became apparent. The community-based model that was developed, the Philani model, recruits and trains Mentor Mothers. It differs from other community health worker (CHW) models in different ways. The main difference is the level of supervision and support given to the Mentor Mothers. Ingrid has always put a strong emphasis on the accountability of the Mentor Mothers, realising that in order to be effective and actually make an impact there must be a high demand on intervention delivery. This approach has proven to be successful and the Philani model has through research studies in collaboration with Stellenbosch University been scientifically evaluated.

With the experiences from the successful Master’s program on HIV/AIDS and the longstanding support to Philani, Church of Sweden responded to the call from Sida by setting up a project on Health, Gender and Theology. Since this in different ways was a new way of working it was labelled the Pilot project. It consisted of three main components: a Master’s program on Health, Gender and Theology/Religion, a training intervention for church leaders, and the Philani model for community outreach. The Master’s program was inspired by the previous one on HIV/AIDS and four academic institutions were chosen; Stellenbosch University and University of KwaZulu-Natal (UKZN) in South Africa, Makumira University in Tanzania and Ethiopian Graduate School of Theology (EGST) in Addis Abeba, Ethiopia. The main idea was that the Master’s programs, training future church and opinion leaders, should be connected to an outreach program based in the Philani model. Stellenbosch was to team up with Philani in Khayelitsha outside Cape Town and in Ethiopia EGST would set up a Mentor Mother project in connection to the school. For Makumira and UKZN new and independent outreach projects were to be established, contextualising the Philani model in the respective setting. Swaziland was chosen as a suitable location both because of previous contacts and collaborations, but also because of the social and cultural situation in the country, with high levels of gender-based violence and the world’s highest prevalence of HIV. The connection between academia and outreach was thought to be beneficial to both parties, as a source of relevant research priorities for the Master’s students and as a resource for training and development for the outreach projects.

As a third component in the Pilot project, a training and workshop package for church leaders was to be developed. Based on previous experiences from the work on HIV/AIDS, this group had been identified and acknowledged as important for advocacy work. Pastors, ministers and priests hold a strong normative power, their opinions count and what is communicated through the churches has a strong impact in the African setting. The participants in workshop series for church leaders were intended to be a support function for the outreach project and a source for interaction with Master’s students. In Ethiopia and Tanzania, EGST and Makumira should take care of all three components of the Pilot idea, in Swaziland an independent NGO called Church Forum was assigned to do the church leader training and in Cape Town no suitable partner was identified. All in all, there were ten different sub-projects in the Pilot, four Master’s programs, three outreach projects and three church leader trainings. The context differed, which added further to the notion that this was indeed a pilot project, testing and trying new ways of working, fixing the plane as it was flying.

Chapter 1

Added value

In February 2013, my wife Elisabet saw a job advertisement in the paper that she thought would be fitting for me. Church of Sweden was looking for a project manager for a maternal and child health project in southern Africa. I was at that time doing my residency in paediatrics at the university hospital in Uppsala and was in the finishing stages of a post-doc project focusing on equity in maternal and child health. The announced position indeed looked interesting and would fit well both with my previous job and research experiences as well as with my desire to work in an international context, gaining field experience. But the choice to apply was not obvious. With four children in different ages, a wife with a good job as a minister in a nearby congregation and with an unfinished specialisation as a medical doctor, the uprooting of me potentially getting a job in southern Africa seemed too big. In addition, our youngest son Zacharias, four years old at the time, had recently been hospitalized with major surgery, and moving to an unknown setting far away from home seemed a bit frightening. But the prospect of working for the church abroad, with a task closely related to my core professional interests was tempting. As a family, we had ten years earlier, while I was still in medical training, been offered to go to Tanzania to engage in the church’s HIV prevention work. At that time, we had turned the offer down after great consideration and agony. In retrospect, this has grown to become a good decision, but the notion of a missed opportunity has lingered on. Maybe this helped in the decision to apply this time.

Some months later I was offered the position. I was going to Swaziland to work as a project manager, setting up an outreach project based on the Philani model. First, we had to check the map and find out where this small and exotic country was situated. Then came the time to decide on whether to accept or not. During this time, our son had a relapse and had to undergo surgery once more. This of course hampered our enthusiasm for the project of going to a new and unknown country far away and sowed doubts to whether it was a good idea or not. Questions of responsibility and safety surfaced. What if our son needed more surgery? Could we gamble with his life and leave the proximity to advanced and qualified care? And with an extended perspective, was it a good thing to uproot the children at all and move to a distant place with a different culture? The answer to the last question we had no problem with, having seen many different places together and been infected by the beauty and curiosity of different cultures and perspectives. To be able to give our family the experience of living in a place other than Sweden was a strong argument for moving, sure that it would become an enriching experience for all of us. Then the issue of the health and well-being was more difficult. But on the other hand, the whole project was about improving health in a setting where access to care was not to be taken for granted. Our hesitations then became a reflection of the unjust world we live in. Being privileged by living in Sweden, we would also be privileged in Swaziland. Even if the distance to good health care would be longer it would not be absent for us, and with good insurances provided by our employer we would have access to the same quality of care as if living in Sweden. In comparison to the people we were going to work together with we would not lack much to protect our own health and that of our son in case something bad would happen. Nevertheless, you are always closest to yourself and many advised us not to accept the offer to go to a country far away. But the doubts soon receded, given the clear and well-prepared path made available to us, fulfilling a dream of old, and well-suited in time. With God’s grace and the comfort of many prayers we decided to accept the offer and move to southern Africa.

After the contract had been signed, I briefly discussed with one of the people who interviewed me for the job why I had been selected. Among all the applicants I had been the only one to mention my desire to work for the church specifically. Many other applicants had relevant experiences and good expertise within project management and maternal and child health, but no one had elaborated on the role of the church and the importance of a theological standpoint except me. Being a man was also to my disadvantage since I was expected to work and lead an organisation of women. Despite this I was offered the job, largely because of the interdisciplinary nature of the Pilot project. The will and understanding that the project was not primarily a health project, but an intention to discern and develop the role of religion and theology in relation to health, was considered more important to Church of Sweden than management skills and previous field experience.

In May 2013, Elisabet and I met with many of the others involved in the Pilot project at a workshop in Sigtuna, Sweden. Some of the sub-project had already started in the fall of 2012, others were in the making. Many of the discussions circled around the contribution of the church in health and what would be the added value of working with an interdisciplinary approach. Hans Rosling, the very popular global health professor at the time, had been asked to join the project group. His reply was that churches should not be involved in health work. Dealing with health should be left to health professionals, he said and declined the offer. This standpoint was in direct opposition to the project idea, but also became a strong challenge to really define the contribution of faith-based organisations in dealing with health problems. Previous experiences and a long tradition of diaconal work supported a general notion that Rosling was wrong, but in order to move forward, a more mature and reflected position was needed. It was no longer enough to rely on missionary hospitals and a history of health care work in places where there was no other provision than what was offered by churches and missions. Development over the past forty years had changed the scene, with the development of the Health for All concept at the Alma Ata conference in 1978 to an integrated and globalized world with a dissolved bipolarity making unilateral efforts from north to south more and more anachronistic. This was Rosling’s main argument and his life task, to spread the knowledge about the tremendous successes and changes within health and healthcare provision. With this rapid development at hand there was, and still is, a strong need to redefine the role of churches as health care actors.

So, what was the idea of the Pilot project? How could churches and faith-based organisations contribute to better health for women and children? Sida had made the request, with an unclear mandate and intention, for Church of Sweden to contribute. Maybe this came from the realisation that religion as a social determinant and important aspect of development work had been lost in the Swedish aid programs. With rising concerns about religious fundamentalism all over the world, not only the Islamic version, but also more out-spoken Hindu fundamentalism in India and an ever-strong Evangelical political base in the US as examples, it had become apparent that religion cannot be ignored in international relations. The pertinent question was how to draw on the vast experience and tradition within the religious community to improve health for all. Traditionally the church has been involved in health care work. The whole nursing system is developed from the monasteries, reflected in the fact that nurses are still referred to as sisters. Missionary hospitals are legio, especially in Africa, and almost all churches have some kind of health-related branch or project. This fits well with the evangelical notion of caring for your neighbour and the biblical thought about stewardship, thus becoming an essential consequence of repentance and sincerity of faith. But it does not mean that the church’s involvement in health work should not be scrutinized by Jesus’ principle of always testing the intention. Why are churches today meddling in health care provision? Wouldn’t it be better, like Rosling expressed, to leave it to health professionals and let governments with more secure funding and with another kind of commitment build capacity to provide health for all? And if churches still want to or see the need to provide health care or health promotion, is it performed so that it serves the end user in the best possible way? Good intentions can many times excuse lack of competence, and perceived expectations of what a church should do can create structures that become necessities in themselves rather than effective means to reach an end. The question it all boils down to is: Why should the church be involved in health care work?

One answer to those questions is that health is a very wide concept. WHO defines health as the lack of any ailment, and the full use of each person’s potential. This utopic definition sets a goal to strive for, ensuring that the WHO will never be out of work. It also testifies that health is something more than the biological well-functioning body. Mind and spirit are equally important for good health and having a dichotomous view in health care, neglecting the spirituality of human beings while focusing on healing the body will always be a limping venture. Here the church has a role, to provide its experience and expertise of handling existential matters, and should provide its services without making excuses for itself. This needs to be done without superstition and pride. In a biomedical hegemony the church needs to reclaim the holistic perspective, not through going back to old thought systems and outdated interpretations, but to actively process and incorporate the latest advancements in medicine and science in theology. This would advance health care and the strive to reach the WHO definition of health.

Another answer to the question why the Church should be involved in health care is the commanding example of Christ. Jesus always took the party of the disadvantaged and poor; the scorned and discriminated. The inequity in health in the world today is not only an economic and moral problem, but a giant revelation to the church where it should be making its presence known. To be a follower of Christ, the Church needs to show solidarity with the worst off. It can be argued that the Church needs to heal the world, oppose oppression or feed the hungry. Those deeds are virtues and something Jesus did, according to scripture. But it is also clear that the New Testament way of doing things is paradoxical to the human standard procedure. When we face injustice the moral gut feeling is to oppose it and make it go away. When Jesus faced injustice, he took it on himself, he stayed in it, he confirmed its existence, and thus restored the disadvantaged and abused. And he told his Church to do the same and let God be the judge. This is an argument for the Church’s involvement in health care, to be where the need is. To take part in the suffering of humanity like a Mother Teresa, a Henry Nouwen or a Florence Nightingale. This is however different from running an NGO, a clinic or an orphanage, but it is an approach that needs to permeate all those activities, because it is the only way to restore and empower a broken world. To see and acknowledge each other as human beings of equal value and status is the only way to challenge the hierarchy of social position that causes unjust health outcomes. The knowledge of this Christ perspective is not a small contribution from the Church to health care, but is offering true empowerment.

A third argument for the Church’s role in health care is the bad health it has already caused. Major advances in biomedicine and public health have been made in providing better health for millions of people over the past decades. Yet there is an appalling high number of people suffering and dying every day despite the presence of this knowledge. One main contributor to this situation is in many places the cultural norms and traditions hindering or delaying adequate care-seeking or healthy behaviour. Religious concepts and traditions are part of this culture and often the hardest to change. The subordination of women, claimed to find its justification in Scripture, is a blatant example of the negative impact on health caused by religious structures. Not only do women and children suffer from the low social position assigned to them but it is an order affecting the whole society, bereaving it of