The Role of the Buddhist Chaplain in Global Health
Thesis Completed As Part Of The Upaya Buddhist Chaplaincy Training Program
David G. Addiss March 2011 – March 2014 April 13, 2014
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Contents
Abstract 3
Acknowledgements 5
Introduction 6
Methods 9
Global health 11
Spiritual challenges for global health practitioners 16
Global health and Engaged Buddhism: shared values and foundations 26
Global health values 26
Three tenets of the peacemaker 29
Foundational principles of public health 32
What can Buddhism offer global health? 34
The global health chaplain 36
Pastoral care 38
Healing 41
Theological support 42
Change agent 43
Direct service to global health “recipients” 44
The Buddhist chaplain and global health 44
Lay Buddhist chaplains in global health 45
Conclusion 46
References 49
Tables and figures 55
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Abstract
The emerging multidisciplinary field of global health is rooted in awareness that all life is interconnected and that people who live in poverty suffer a disproportionate share of the global disease burden. At its best, global health represents a compassionate, coordinated response to human suffering and a commitment to health equity through systemic change. Many, if not most, of those who enter the field of global health are motivated by spiritual values of compassion and service, but they frequently find it difficult to bring these values fully into their work. Some global health workers are traumatized by repeated exposure to intense suffering in resource-limited settings, while others, particularly in large organizations, find themselves spiritually isolated, disconnected from the compassion that initially inspired them and alienated from the people they seek to serve. Opportunities for global health practitioners to collectively acknowledge the spiritual impulse that led them to this work are virtually non-existent, even in training programs. Global health workers are further challenged by commercial, institutional, and political interests that increasingly dominate the field; the need to justify programs in economic terms; the challenge of “seeing the faces” when working to improve health of entire populations; and an assumption that scientific rigor and clinical competency are incompatible with emotion or “soft” values.
Despite the range and depth of spiritual challenges faced by those in global health and the fact that spiritual values, especially compassion, are an important source of inspiration for their work, very few global health organizations have chaplains. In this thesis, I consider the importance and potential role of the chaplain in global health; explore the shared philosophical and ethical foundations of global health and Engaged Buddhism, with an emphasis on the centrality of compassion; and suggest that the Buddhist chaplain, with a deep understanding of
4 suffering and inter-being, and grounded in compassion and non-dualism, is well-equipped to address the spiritual needs of individuals in global health and to facilitate needed structural change in the complex, dynamic international system of global health.
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Acknowledgements
I am deeply indebted to a “great cloud” of teachers, colleagues, and fellow-travelers who have encouraged, inspired, and enabled me to see and experience more clearly the themes that I try to articulate in this thesis. Through my work, I have had the privilege to meet, learn from, and collaborate with some of the world’s most creative thinkers, leaders, and exemplars in global health. Those who especially shaped my development and thought on compassion and spirituality in global health include George Alleyne, Abhay Bang, Maggie Baker, Stephen
Blount, Molly Brady, Jimmy Carter, Sarla Chand, Jeannine Coreil, Gail Daveys, Paul Derstine,
Gerusa Dreyer, Paul Farmer, Bill Foege, Alan Foster, Johnny Gyapong, Adrian Hopkins, Don
Hopkins, Geoffrey Knox, Patrick Lammie, Adetokunbo Lucas, Jim McAuley, Deb McFarland,
Wayne Melrose, Eric Ottesen, S.P. Pani, Christina Puchalski, C.P. Ramachandran, K.D.
Ramaiah, Frank Richards, Mark Rosenberg, David Satcher, Bernhard Schwartländer, R.K.
Shenoy, David Shlim, Richard Stanley, Tom Streit, Judd Walson, and Angela Weaver.
In addition, my life has been blessed through association with religious and spiritual leaders, thinkers, and practitioners, whose lives have touched mine in profound ways and opened me to the possibility of a compassionate life. Among them are John Albert, Doug Burton-
Christie, Joan Chittister, His Holiness the Dalai Lama, John Dunne, Wendy Farley, Bernie
Glassman, Alon Goshen-Gottstein, Fran Henry, Thupten Jinpa, Ben Campbell Johnson, Thomas
Keating, Fleet Maull, Beth McLaren, Parker Palmer, David Steindl-Rast, Archbishop Desmond
Tutu, Bill Vendley, and Miroslav Volf. My life has been further enriched by neuroscientists, physicists, and peacebuilders, whose deep dialogue with the spiritual is opening new vistas for the future of humanity: Richie Davidson, Jim Doty, Joel Elkes, Mark Gopin, John Paul
Lederach, Chuck Raison, Cliff Saron, and Arthur Zajonc.
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The Upaya Buddhist Chaplaincy Training program provided an excellent container for this exploration, for which I am profoundly grateful. I am deeply indebted to Roshi Joan Halifax for her teaching and encouragement, her profound understanding of suffering, and her embodiment of compassion. I am grateful for the wise guidance of Maia Duerr, the compassionate encouragement of my mentor, Bruce Cowgill, the fellowship of my chaplaincy cohort, and the life-giving accompaniment of my mentoring group, Claire Willis and Julie
Connelly. In addition, I am indebted to Andrew Dreitcer, Frank Rogers, and Mark Yaconelli, whose generous invitation to participate in their course at the Claremont School of Theology,
The Way of Radical Compassion, reacquainted me with the radical compassion of Jesus.
Special thanks to Chris Crowe and Jean Ogilvie for encouragement and expert discernment on the path, and to my men’s group in Kalamazoo: Mark, Don, Skip, Paul, Tom, and George. I thank Beth McLaren for helpful suggestions on the manuscript. Most of all, I am grateful for Julie, my Beloved, whose love, encouragement, discernment, and precious life immeasurably enriches my own, day after day.
Introduction
This thesis marks a milestone on a personal journey. After working as a general medical practitioner in a rural migrant health clinic in California, I received training in public health at the Johns Hopkins University and joined the Centers for Disease Control and Prevention (CDC) in 1985. CDC provided me extraordinary opportunities in global health. I learned from some of the best. I completed temporary assignments for the World Health Organization (WHO) in
Sudan, Pakistan, Nigeria, and the Dominican Republic. My study and research on lymphatic filariasis and other tropical parasitic diseases took me to Haiti, Brazil, China, India, Sri Lanka,
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Guyana, Surinam, Malawi, and Ghana. I was part of a small, collegial, highly committed group of “zealots” whose research and advocacy were paving the way for a global program to eliminate lymphatic filariasis, a tropical parasitic disease, and its disfiguring, stigmatizing consequences.
It was a fulfilling, exciting adventure.
But all was not well. On September 11, 2001, the World Trade Centers in New York
City were attacked. The groundwork already being laid by the Bush administration to bring the
US Public Health Service into line with the administration’s national and foreign policy objectives took root in a nation gripped by fear. CDC’s top priority became bioterrorism defense and “homeland security.” The ethos with the organization shifted overnight, from public health to civil defense (Altman, 2002). While both public health and civil defense are necessary for national interests, I believe that they have their origins in sharply contrasting worldviews.
In such an environment, global health work became increasingly difficult, especially for those of us who were Commissioned Officers in the US Public Health Service. The
Commissioned Corps was “revitalized” to support civil defense, emergency response, and national security objectives rather than established public health priorities. The global health agenda suffered. With my identity so heavily invested in my work, I experienced these setbacks as personal failures. My personal life was also in trouble, a consequence, in part, of the single- minded “zeal” with which I had thrown myself into my work. In 2006 I left CDC, discouraged, emotionally spent, and bitter.
I found work at the Fetzer Institute, where I directed their program in science and spirituality. While there, I became increasingly interested the role of compassion in global health and in the connection between the inner life of spirit and one’s work in the outer world. I realized how seldom my colleagues at CDC and I had ever spoken about our spirituality,
8 motivations, or values. On the occasions when I would visit them, I began to ask them to “tell me in one word why you do what you do.” When willing to play this game, they became silent and thoughtful, and their voices dropped low. Invariably they responded with words such as
“compassion,” “concern,” and “caring” – even “love.” I was struck by the power of the question and by the consistent theme that emerged – about which we had never spoken. I began to perceive a collective sense of spiritual isolation and wondered what power might be unleashed if we could begin, quietly, to speak of our shared values, of the spirituality that inspired our work.
I teamed up with Mark Rosenberg, President and CEO of the Task Force for Global
Health to organize a small gathering of global health leaders at The Carter Center in September
2010. We asked these leaders to explore and reflect on the theme of compassion in global health and on the role of compassion in their lives and career. For me, it was a pivotal meeting that affirmed the centrality of compassion in global health.
In March 2011, I entered the Upaya Buddhist Chaplaincy Training Program, which set me on the journey of “inner chaplaincy.” Chaplaincy, especially as envisioned at Upaya, provided a powerful and creative lens through which to understand and address the spiritual hunger that I had experienced myself and witnessed in my global health colleagues.
In October 2011, I returned to the field of global health as director of Children Without
Worms (CWW), a program at the Task Force for Global Health. Supported by the pharmaceutical companies Johnson & Johnson (J&J) and GlaxoSmithKline (GSK), CWW aims to prevent intestinal worm infections in 600 million at-risk school-age children and to facilitate their treatment with deworming drugs that J&J and GSK have donated to WHO. This position offered me several opportunities. First, it was a chance to determine whether I personally could
9 work in the field of global health more spiritually grounded and self-aware than I had previously.
Could I put into practice what I was learning at Upaya? The jury is still out.
Second, it offered an opportunity to participate in a fascinating convergence of the major corporate, private, and governmental “players” in global health – all dedicated to improving the health of neglected populations. The job provides me a ring-side seat from which to witness both the expression and the constriction of compassion, and to observe where it pops up unexpectedly. It also has given me access to some of the world’s global health leaders and provided occasions for private conversations with them about what most matters.
Finally, my return to global health has provided more formal opportunities to explore and understand the role of compassion in global health. I helped organize a symposium on compassion and tropical medicine at the 2011 annual meeting of the American Society of
Tropical Medicine and Hygiene, which received an overwhelming response from a standing room-only crowd of scientists eager to share their own stories. Additionally, I have had the privilege of speaking to students, physicians, chaplains, and nurses about compassion in global health at conferences and other gatherings.
For the past three years, compassion and global health has been my koan. This thesis is an offering of my reflections to date. I am fully aware that I am just scratching the surface and that the depths of the koan have yet to be explored and realized.
Methods
I relied on several sources to guide the inquiry that led to this thesis. The core requirements and electives for the Upaya Buddhist Chaplaincy Program provided spiritual formation, insights, and conceptual tools. This was supplemented with readings on compassion,
10 spirituality, chaplaincy, and global health, some of which are noted in the references section.
The Pitts Theology Library at Emory University was a rich source of material. Unpublished transcripts from the September 15-17, 2010 meeting at The Carter Center were a useful starting point for my exploration of compassion and global health. A video summary of this meeting can be seen at http://www.taskforce.org/press-room/videos/compassion-global-health-video.
I conducted formal and informal interviews with dozens of global health leaders, students, and colleagues, many of whom are named in the Acknowledgements. My colleagues shared insightful and honest reflections, often over dinners and coffee breaks during global health meetings. I also solicited ideas, thoughts, and feedback from those who listened to the following presentations I gave on compassion and global health:
Compassion and Authenticity in Global Health. Navigating Global Health Ethics, 2nd
Annual Participatory Dinner and Discussion, Emory Public Health Ethics Club, Rollins
School of Public Health, Emory University, Atlanta, Georgia, October 1, 2013
Global Health: Got compassion? Forum on International Health and Tropical Medicine,
Washington University School of Medicine, St. Louis, Missouri, April 27, 2013
Extending the Benefits. 7th Meeting of the Global Alliance to Eliminate Lymphatic
Filariasis. The World Bank, Washington, DC, November 19, 2012 (Addiss, 2013)
Compassion and Paradox in Global Health. Fifth Annual Pediatric Global Health
Symposium. The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,
September 21, 2012 (http://www.chop.edu/export/download/pdfs/articles/global-
health/2012-symposium-presentation-compassion-and-paradox.pdf)
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Compassion and Global Health. 4th Annual Spirituality and Health Summer Institute.
The Georges Washington Institute for Spirituality and Health, George Washington
University, Washington, DC, July 12, 2012
Symposium on the Impact of Compassion in Global Health and Tropical Medicine.
Annual Meeting of American Society of Tropical Medicine and Hygiene, Philadelphia,
Pennsylvania, December 7, 2011.
As I documented these conversations, either in summary notes or, when possible, in audio recordings, four key spiritual challenges emerged for global health practice, which I explore in this thesis. I am indebted to numerous conversations with global health practitioners, chaplains, and others for sharpening my arguments and enriching the ideas presented herein.
Global Health
The dynamic, complex, and emergent nature of global health frustrates attempts to define it. The aims of global health are to improve the health of all people and to achieve health equity worldwide (Koplan et al., 2009). The field emerged during the 1990s as a response to novel infectious disease threats, the globalization of the economy, the environmental movement, and new public health partnerships and alliances (Brown, Cueto, & Fee, 2006). Global health is rooted in public and international health but is distinguished by its global geographic reach, its emphasis on multidisciplinary collaboration and multilateral coordination, and its embrace of both prevention and clinical care (Table 1).
Structurally, global health is a complex meta-system that includes not only the health systems of all nations, but also local and international non-governmental organizations (NGOs); foundations such as the Bill & Melinda Gates Foundation; United Nations agencies such as
WHO, UNICEF and The World Bank; bilateral aid and development agencies such as the US
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Agency for International Development (USAID); faith-based groups; primary healthcare workers; health volunteers; academia; corporate philanthropy; business; public-private partnerships and alliances such as the Global Fund, UNAIDS, and the Global Alliance to
Eliminate Lymphatic Filariasis (GPELF); and, increasingly, the military. In addition, during the past decade there has been an explosion of interest in global health among students and health professionals. Positions in medical residencies and fellowships that focus on global health are in great demand, and global health courses in schools of public health – and in undergraduate universities – are extraordinarily popular (Hill, Ainsworth, & Partap, 2012).
Global health is much less a cohesive set of organizational structures than it is a network of relationships that transcends the usual human boundaries of geography, nationality, economics, and politics. As the distinguished Nigerian physician Adetokunbo Lucas has noted, solutions to health problems do not always appear in the same place as the problems themselves, and global health joins the two.
This principle can be illustrated by ivermectin, the only safe and effective drug for onchocerciasis, a parasitic disease that causes blindness as well as disabling itching of the skin in sub-Saharan Africa. Initially isolated from a fungus found on a golf course in Japan, ivermectin was developed as a veterinary drug by researchers in Australia; first tested in humans by Dr
Mohammed Aziz, a scientist at Merck & Co, Inc. who was born in Bangladesh but had worked in Sierra Leone, where onchocerciasis is endemic; and evaluated for its potential against onchocerciasis by a global network of scientists organized by WHO (Campbell, 2012). Because those with onchocerciasis could not afford ivermectin once it was approved for human use, in
1987 Merck & Co., Inc., in Rahway, New Jersey, pledged to donate ivermectin free of charge for as long as needed to control and eliminate onchocerciasis. Some 1.5 billion treatments have
13 been donated for this purpose in West Africa and Latin America, greatly reducing the prevalence of blindness and leading to the elimination of the infection in some countries (Mectizan Donation
Program, 2013).
The ivermectin story is an excellent example of how global health, at a fundamental level, is grounded in an understanding that all life is interconnected, that the health of all beings is interdependent. This awareness bears fruit in compassionate action. In September 2010, a group of prominent global health leaders attended a two-day meeting on compassion in global health at The Carter Center. They concluded, “Global health is rooted in the value of compassion. It is grounded in an awareness of our interconnectedness and a concern with the whole. Global health and compassion both seek to build bridges between people who are separated by geography, politics, resources, and other factors” (Addiss et al., submitted). From this inherent sense of interconnectedness, global health seeks to address and transform the suffering of some of the most marginalized and neglected populations on earth, often in extreme situations such as refugee camps, famines, armed conflict, or desperate poverty. It does this through the coordinated action of organizations, networks, and alliances to effect systemic change.
Global health action is guided by the science of epidemiology. Epidemiologists collect data on adverse health outcomes, analyze these data to identify risk factors, and intervene through programs and systems to reduce or modulate these risk factors and improve health outcomes. Thus, global health is science-based; it depends on data for decision-making and for assessing impact.
Yet, in a speech in 1984, CDC’s former Director, Bill Foege, challenged the organization to look beyond the numbers: “If we are to maintain the reputation this institution now enjoys, it
14 will be because in everything we do, behind everything we say, as the basis for every program decision we make – we will be willing to see faces” (Foege, 1984). This was an extraordinary message for a public health institution, responsible for the health of populations, not individuals.
CDC’s reputation would depend not on programmatic effectiveness, measurable outcomes, or epidemiologic prowess, but on compassion – the willingness of its employees, collectively, to see the faces of suffering.
In 1999, Foege extended this view. He wrote, “Successful public health leadership in the next millennium will require….the ability to see the whole and its parts simultaneously. Public health leaders…need to scan and to focus and to see relationships. And they need to do these all at the same time” (Foege & Rosenberg, 1999). In a speech at the Task Force for Global Health in Decatur, Georgia on April 26, 2012, Foege said, “Everything is local and everything is global.
Global health is not ‘over there’ – it’s right here.” Thus, for global health to realize its promise of transforming the suffering of entire populations, its practitioners must have the capacity to remain in relationship with individual human “faces” while immersed in the numbers, to see the whole and the parts simultaneously, and to move seamlessly from local to global and back again.
Julio Frenk, Dean of the Harvard School of Public Health, echoes this non-dual perspective when he says, “The greatest threat to global health is dichotomous thinking” (Frenk, 2011).
From countless conversations with global health practitioners and students over a period of several years, I have been impressed by the degree to which those who enter the field do so out of a profound sense of interconnectedness, motivated by compassion. Yet, global health is outward-looking, science-based, problem-oriented, and highly practical – even, at times, mechanical. Shared values and personal motivations are rarely discussed in global health circles.
Even Paul Farmer, the well-known anthropologist-physician whose influential work is rooted in
15 a sense of calling and inspired by liberation theology, does “not feel authorized to talk about love, compassion or religion” in educational institutions that train global health leaders (Farmer,
2010).
This collective silence on global health’s core values tends to isolate individuals in the field and allows influences other than compassion to operate unchallenged. Fear is a critical countervailing force to compassion, especially fear of external threats. For example, fear of contagion forms the basis of the practice of quarantine, for centuries a mainstay for preventing importation and spread of communicable diseases (Cetron & Landwirth, 2005). Fear of bioterrorism during the Cold War led to the creation of the elite cadre of disease detectives, the
Epidemic Intelligence Service (EIS) at CDC (Pendergrast, 2010). Concerns about domestic security blurred the line between public health and civil defense after September 11, 2001 as
CDC epidemiologists began to collaborate more closely than ever with law enforcement (Butler,
Cohen, Friedman, Scripp, & Watz, 2002) and funds allocated for bioterrorism preparedness assumed a large proportion of CDC’s budget (Altman, 2002; Heinrich, 2002). National security and protection of military and business interests are not new on the global health stage. Tropical medicine originated during the late 1800s primarily to protect European soldiers and colonists rather than to improve the health of those they colonized (Farley, 1991).
In summary, global health is a complex field, deeply rooted in relationship and paradox.
The practice of global health involves tensions between individuals (“faces”) and populations
(“numbers”); between the whole and the parts; between local and global; between the compassionate impulse that is so important for many practitioners and the bureaucratic, efficiency-driven, institutional environments in which they work; between a sense of spiritual hunger and isolation among many individual practitioners and their collective silence on their
16 shared values; and between core values of interconnectedness and compassion and the increasingly pervasive influences of politics, national security, military interests, and profit- making in global health.
Leaders such as Bill Foege would argue that these tensions must be understood and embraced for global health to realize its full potential. At its best, I believe, the practice of global health is a spiritual discipline.
Spiritual challenges in global health
In interviews and conversations with numerous global health leaders, students, and practitioners, four key themes emerged to describe some of the spiritual challenges that they face. These themes are rooted in the global nature of the field and the central role of compassion within it. I refer to the four themes as dichotomous thinking; barriers to compassion; the taboo of the personal; and saving the world.
Dichotomous thinking
The dualism faced by the global health practitioner can be considered a modern manifestation of the ancient problem, addressed by Greek philosophers, of “the one and the many.” As Johnston (2004) frames the question, “How do we reconcile the experience of unity with the experience of multiplicity?” How can the global health practitioner be fully aware of the faces and the numbers, reconcile the local and the global, or be motivated by a profound sense of humanity’s vast interconnectedness and be fully attentive to seemingly endless, minute technical details – at the same time? The problem of “the one and the many” cannot be solved by the dichotomous thinking that creates it.
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Dichotomous thinking lies at the very foundations of global health. Epidemiology depends on binary classifications: healthy or ill; living or deceased; exposed or not exposed. In epidemic investigations, specific case definitions are established to distinguish, as clearly as possible, cases (persons with the condition of interest) from controls (those without the condition). Binary classification has proven an extraordinarily powerful tool for understanding disease, its causes, and contributing factors.
In many ways, however, adherence to dichotomous thinking within global health seems paradoxical. Thanks to air travel, global health practitioners can, as I used to, leave their modern, well-equipped laboratory at CDC in the morning and, that same evening, examine patients with lymphatic filariasis in a remote village in Haiti. They enjoy meaningful collaboration and friendships with colleagues around the world, and participate in the remarkable transformation of ideas into protocols, relationship-rich field experiences into data, data into scientific publications, and research into policy (Butler, 1996). Through their work, the usual dichotomous categories of “here or there,” “local or global,” “my people or others,” and “faces or numbers” dissolve.
Despite this experience, Foege and Frenk are among the very few thinkers who have pointed to the limitations of dichotomous thinking for global health practice. There seem to be few in the field who can hold “the faces and the numbers” at the same time, yet that capacity for non-dualism may be precisely what is required for global health leadership (Foege & Rosenberg,
1999). The inability of global health practitioners to move, with intention and self-awareness, beyond the confines of dualistic categories that they embody creates an inner dividedness, an unspoken form of interior suffering, that adversely affects the practitioners themselves, the people they seek to serve, and the field as a whole.
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Compassion
As already noted, compassion is a cornerstone of global health and a key source of motivation for those who enter the field. However, once engaged in the work, many find it difficult to remain connected to their compassionate impulse. Unlike clinical settings, in which nurses, physicians, and chaplains are directly exposed on a daily basis to the faces of suffering, global health reaches across great geographic distances to improve the health of entire populations. In Bill Foege’s words, the focus is almost entirely on the numbers. People who work in these institutions may literally never “see the faces” of those they seek to serve.
Anthropologists tell us that humans evolved in small groups or tribes, which served as crucibles for the development of identity, trusting relationships, and compassion. We seem to be hard- wired for intimacy and deep relationship with relatively few. Yet global health seeks to address the immense suffering of millions. What does it mean to have compassion for entire populations? Practically, what tools are available to awaken this human potential?
To understand the particular challenges to compassion in global health, a model described in various forms by Batson, Fultz, & Schoenrade (1987), Eisenberg (2002), and
Halifax (2011) is especially helpful (Figure 1). The tools of global public health, the means through which compassion is expressed and suffering relieved, are not direct and personal, as in the clinical setting – a touch on the shoulder or a gaze into the eyes – but rather, organizational in nature, e.g., program planning, budgets, grants, protocols, training, evaluation, and logistics.
Global health practitioners may be cognitively aware of the suffering they are working to relieve or prevent, but the empathy or empathic resonance that is necessary for compassion (Figure 1), is often insufficient. Negotiating the bureaucracy, policies, and politics of their own organizations, while ultimately necessary to mobilize resources needed to address the suffering of populations,
19 can further distract and divert attention away from the faces of suffering. The empathic signal easily fades to the point of extinction, and this can occur within in a relatively short period of time. I have spoken with many young global health professionals, just a few years out of public health school, who express disillusion, loss of idealism, and estrangement from the people they intended to serve.
Global health practitioners whose tasks are largely administrative, who work in large organizations, and who live in capital cities, whether in Washington, DC or Paramaribo,
Surinam, find that they feel renewed, refreshed, and reconnected when they leave their offices and “go to the field.” There, the impact and human dimensions of their work become more tangible, they become reacquainted with the faces of suffering, and the emotional resonance required for compassion is rekindled. Another practice that global health practitioners use to help them remember is to decorate their offices with photographs “from the field.”
Thus, intuitively, global health practitioners recognize the need for empathic arousal; they tend to address this primarily through immediate experience (travel to the field) or tangible images (e.g., photographs). At the same time, Dr. Abhay Bang, Director of the Society for
Education, Action and Research in Community Health (SEARCH) in Gadchiroli, Maharashtra,
India has suggested that compassion for populations requires a certain capacity for abstraction, for seeing the faces in the numbers, and that this is enhanced by spiritual practice, which enables one to feel deeply connected to all of humanity (Bang, 2010). Connection with the tangible and the capacity for abstraction are not incompatible; both are needed.
We have noted the challenge of an insufficient emotional stimulus, but at the other extreme, global health workers not infrequently find themselves immersed in situations of overwhelming, extreme suffering which, coupled with inadequate resources and at times,
20 personal danger, can trigger profound emotions of helplessness, fear, inadequacy, and anger.
Those who work in refugee, disaster, or relief settings or in zones of conflict, instability, or violence are particularly susceptible. Unable to adequately emotionally regulate, and without the capacity to transform the suffering around them, they experience high levels of personal distress, which is much more likely to lead to the responses of fight, flight, or freeze than to compassion
(Figure 1).
The taboo of the personal
A third spiritual challenge in global health is its outward-looking culture that provides little space for collective reflection on values, personal stories, meaning, or purpose. Dozens of books and articles have been written on justice and global health, but very few on compassion, which is remarkable given the importance of compassion as a motivation for so many in the field.
The photo on the cover of this thesis is that of an enso, which used to hang in the dining room of Upaya Zen Center. I am told that it was painted by Thich Nhat Hanh. When I first saw it, I stopped in my tracks. What could “peace in oneself” possibly have to do with “peace in the world?” (Further, what could “oneself” possibly mean in Buddhism?) Global health practitioners exhaust themselves working for peace (health) in the world, but often severely neglect peace within. Several factors contribute to this. First, given the immensity of suffering and disease in the world, any focus on peace in oneself is considered a luxury, a distraction to the vastly more important work of global health.
Second, as noted earlier, global health is grounded in the science of epidemiology. In general, scientists tend to be more comfortable, professionally, focusing outward on the external world of objects than looking inward. Unlike the sciences of consciousness studies and physics,
21 which have had to move beyond subject-object dualism to understand their experimental data
(Zajonc, 2009; Dalai Lama, 2005; Wallace & Hodel, 2007), epidemiology remains stuck in a
Newtonian world view, exclusively concerned with objects in the external world. The scientist, the subject who observes the external world, remains invisible.
Third, global health is highly organizational, distinctively secular, and funded largely by the public sector. In this context, private spirituality may be acceptable, but, at least in Western democracies, public expression of one’s inner life is avoided. With no “safe space” to explore the spiritual underpinnings of global health with their colleagues, many in the field feel a sense of spiritual isolation.
This virtual taboo on collective expression of the inner life seems paradoxical, since many individuals enter the field out of a sense of spiritual calling, with a deep desire to serve.
Further, the decision to enter the field is often shaped by a moving personal encounter with a particular individual, for example during an international service learning project or a medical student clerkship abroad. These personal stories contain tremendous power to motivate, shape, and sustain an entire career, yet they are rarely shared collectively. The exceptions are memorable. For example, on December 7, 2011, a symposium on compassion and global health was held at the annual meeting of the American Society of Tropical Medicine and Hygiene
(ASTMH). The audience – distinguished experts in tropical medicine – lined up to share their personal stories. This email from Ann Varghese, a program officer at IMA World Health, is typical of those that I received afterwards: “The symposium was a milestone for me. I never thought ASTMH would approve a symposium on such a topic. It's also been an individual journey as I try to reconnect with my own sense of compassion and motivation for this work. I
22 was gratified by the response to the symposium, and hope that we find ways to advance the conversation.”
Collective discomfort with the inner life not only leads to a sense of spiritual isolation at the individual level; it impoverishes the field itself and limits its capacity to adequately address issues such as apology and disclosure of wrongdoing, which increasingly are recognized as important in clinical medicine (Wood & Star, 2007). Global health interventions, such as the example of ivermectin treatment for onchocerciasis, mentioned above, may have unintended consequences. Between 1989 and 2001, fifteen apparently healthy people in Cameroon tragically died after being treated with ivermectin and several others suffered permanent neurologic damage (Twum-Danso, 2003). Cameroon is co-endemic both for onchocerciasis and for a related parasite, Loa loa, which can occur at very high levels in the blood (i.e., more than
10,000 worms per mL). It took several years before it became clear that the deaths were causally related to ivermectin treatment and to Loa loa infection. In this situation and others, the barriers to public apology are substantial; they can be seen as a potential threat to the program and to the undeniable benefits that it delivers. Consequently, global health practitioners deal with this in their own way; there are no collective expressions of grief, no ceremonies to honor those whose lives were lost.
Saving the world
The fourth major spiritual challenge in global health is more subtle and, therefore, more difficult to recognize than the others. It represents the shadow side to the sense of calling, mission, and purpose that many global health practitioners experience in their work. While a realization of interconnectedness and compassion may be the primary motivation for entering the field, a career in global health also offers the opportunity to “do good” on a large scale, to have a
23 measurable impact on the suffering of millions of people. The skillful and systematic application of relatively simple technologies can dramatically improve child survival, eradicate scourges such as Guinea worm disease and smallpox, and eliminate the debilitating effects of neglected tropical diseases that affect more than one billion of the world’s most economically impoverished people. Indeed, for physicians and nurses trained in clinical care, global health offers the opportunity to bring lasting health improvements not just to individual patients, but to entire populations.
Thus, a career in global health appeals not only to a compassionate impulse rooted in mature self-awareness, but also to the ego’s desire for significance, identity, and purpose. The sweeping vision and scope of global health presents a compelling case to the ego and serves as a powerful attractant for those seeking to “work out their salvation” or harboring the desire to be affirmed as a good or caring person. Linking one’s identity and self-worth to a field as vast as global health can result in a great deal of frenetic activity in the name of service to others. If not examined, this can be highly problematic, even though it is usually justified on the grounds of the tremendous need. While not referring to global health specifically, Thomas Merton, a
Cistercian monk, described this problem when he wrote, “To allow oneself to be carried away by a multitude of conflicting concerns, to surrender to too many demands, to commit to too many projects, to want to help everyone in everything is itself to succumb to the violence of our times”
(Merton, 1965a).
How does such an excessive self-identification with, and sacrificial focus on, work affect global health practitioners? First, it can adversely affect relationships with family and loved ones. One of the incisive questions that Sharon Daloz Parks used to put to medical students as
24 they entered their clinical training was, “Who among your loved ones will you be willing to hurt in your headlong pursuit of medicine?”
Second, the personal sacrifices one makes to climb the ladder of influence and prominence in global health can lead to resentment and an inability to perceive the shadow side of one’s commitment. As rewarding and important as global health work can be, it is not a substitute for relationship. Conflating personal identity with one’s commitment to global health also makes it difficult to discern when one’s actions, however well-intentioned, may be causing harm as well as good. With such a significant personal stake in one’s work, it can be difficult to welcome criticism or to acknowledge when the outcomes are not as one hoped. Clinging to a good outcome to bolster one’s self-image is inconsistent with a mature understanding of compassion. Rather, over-identification with global health work can lead to so-called “selfish” pro-social behavior (Figure 1).
Third, one of the major challenges in global health is the imbalance of power and resources between “donor” agencies, whether governmental (e.g., USAID) or private (e.g., Bill
& Melinda Gates Foundation), and “recipient” communities. Those on the donor side exacerbate this power differential when they are convinced of the righteousness of their cause, program, or intervention, or over-identify with its success. They unwittingly contribute to top-down
“solutions” to problems that may not be appropriate for local communities. Too often, priorities in tropical medicine and international health have been driven by donors or established as part of a colonial enterprise (Farley, 1991; Gow, 2002). Even highly-acclaimed and successful programs, such as the President’s Emergency Plan for AIDS Relief (PEPFAR), launched by
President George W. Bush, are subject to this criticism (Sastry & Dutta, 2012).
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Global health practitioners certainly are not the only ones who tend to focus on “peace in the world” while neglecting “peace within oneself.” In recent years, spiritual teachers from many traditions have highlighted the dangers in doing so. For example, Joanna Macy (1988) writes, “To heal our society, our psyches must heal as well. The military, social, and environmental dangers that threaten us do not come from sources outside the human heart; they are reflections of it, mirroring the fears, greeds, and hostilities that separate us from ourselves and from each other. For our sanity and our survival, therefore, it appears necessary to engage in spiritual as well as social change, to merge the inner with the outer paths.” This message is echoed by Thomas Merton (1965b), “There can be no peace on earth without the kind of inner change that brings man back to his ‘right mind’.”
In early 2013, I joined several colleagues for dinner in a loud, crowded restaurant in
Manhattan. I was seated next to someone I had never met before, a well-respected communications consultant and HIV/AIDS activist. As the evening progressed, he and I entered a conversation about compassion in global health and the spiritual challenge of “saving the world.” I received the following in an email from him several days later. “I don’t think I had verbalized to anyone before the disconnect I sometimes feel between the compassionate nature of my work, all with nonprofits doing extraordinary public health and social justice work, and my avoidance of dealing directly and compassionately with friends and family who are in psychological or physical distress. Something I’m not proud of but at least I’m concerned about.
So quite unexpectedly you touched a nerve that needed to be exposed so I can understand and deal with it more.”
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Global Health and Engaged Buddhism: Shared Values and Foundations
A basic hypothesis of this thesis is that the fundamental values and worldview of global health are strikingly similar to those of Engaged Buddhism. There also are differences, which we will explore. A serious dialogue between these two fields could significantly enrich global health and begin to address the spiritual challenges mentioned above. This chapter will briefly describe the core values of global health and note the parallels and differences with Buddhism; explore how global health acts on the Three Tenets or Three Pure Precepts; compare the four foundational principles of public health suggested by Foege and Rosenberg (1999) with Buddhist teachings; and consider potential contributions of Engaged Buddhism to global health.
Global health values
Interconnection
Global health is fundamentally shaped by a conceptual and experiential awareness that all life is interconnected. This awareness is intellectually grounded in ecology, infectious disease epidemiology, social theory, and medical anthropology. Global health transcends national boundaries and recognizes that the health of an African villager can significantly influence, and be influenced by, the health of a stockbroker in New York. Buddhism affirms global health’s understanding of interconnection but goes further to include all sentient beings and to emphasize the fundamental spiritual reality of inter-being (Thich Nhat Hahn, 1998), which not only can be understood, but also deeply experienced. In a Bearing Witness to the Oneness of Life retreat at
Upaya Zen Center, August 19-21, 2011, Roshi Bernie Glassman said, “My goal, from the first day I became a Buddhist teacher, has been to help people experience (or realize) the interconnectedness of life…I don’t give a rat’s ass about understanding interconnectedness. I love to understand. But I want to help people experience it.” So while global health as a field
27 may understand interconnection, Buddhism enables one to experience it directly.
Transforming suffering
Both global health and Buddhism are deeply concerned with suffering in its many forms.
Global health is primarily concerned with physical suffering caused by disease or injury, but it also recognizes the importance of stigma, social suffering, and disability. Indeed, for some diseases, such as lymphatic filariasis, these latter forms of suffering have been critical to mobilizing efforts to address them (Addiss, 2013). In addition, global health seeks to prevent suffering in populations, a theme that, to my knowledge, has not been fully developed in
Buddhism.
Although global health views the causes of suffering in terms of risk factors for disease, premature death, or disability, it also would concur with the Buddhist view that suffering arises from ignorance, clinging, and avoidance. Indeed, ignorance, which in epidemiologic studies is often measured through responses to surveys or assessed indirectly through proxy measures such as level of formal education, is consistently one of the strongest risk factors for a wide range of adverse health outcomes.
Global health also would concur that clinging, or greed, particularly as expressed in income inequality, is a major risk factor for health inequity and premature death (Kondo, 2012).
In addition, aversion to the suffering of others, especially of disenfranchised populations, is a major impediment to global health. For example, those who suffer the disfiguring, stigmatizing effects of neglected tropical diseases are most often “at the end of the road;” their suffering is hidden (Hotez, Fenwick, Savioli, & Molyneux, 2009). Dr Donald Hopkins, Vice President of
Health Programs at The Carter Center, often says that the duty of the epidemiologist is to “use data to make the right people uncomfortable” (Hopkins, 2011). Global health breaks through
28 aversion to suffering by showing incontrovertible data of its existence, and demonstrating, through scientific evidence, the effectiveness of specific public health interventions in relieving and preventing that suffering.
Compassion
The critical importance of compassion to both global health and Buddhism may provide the greatest opportunity for fruitful dialogue between the two. As noted above, individual global health practitioners are often motivated by compassion, but they rarely acknowledge this publicly or collectively. Consequently, there is little opportunity within global health to explore one’s interior movements with regard to compassion, to understand the critical importance of emotional resonance, or to realize that compassion does not cling to a desired outcome. As a result, for most global health practitioners, compassion remains unexamined. Buddhism’s rich understanding of the internal dynamics of compassion (Halifax, 2012; Davidson & Harrington,
2002), supported by recent work in neuroscience, specifically on compassion meditation
(Halifax, 2011; Klimecki, Leiberg, Lamm, & Singer, 2012; Lutz, Brefczynski-Lewis, Johnstone,
& Davidson, 2008), could be an extraordinarily important resource for global health practice.
Non-duality
Any mention of non-duality in global health circles would likely be met with blank stares. As noted above, epidemiology, the scientific foundation of global health, is largely based on dichotomous outcomes. Nevertheless, a few global health leaders, such as Bill Foege, in an effort to define this still rather amorphous field, have begun to rely on the language of paradox and non-duality. Foege has essentially argued that the capacity for non-dual awareness (although he does not use this term) is essential for global health leadership. Yet, within global health, there has been little interest in learning how to cultivate this capacity. The spiritual dimensions
29 of non-duality remain completely unexplored in global health.
Justice
Social justice is a core value for global health. Global health issues are often framed in terms of human rights and justice (Gostin, 2012) and considerable attention has been given in recent years to health inequity and the social determinants of health (Commission on Social
Determinants of Health, 2008). Global health seeks social justice through systemic change.
Engaged Buddhism embraces this call for justice, although traditionally Buddhism has focused more on transforming suffering rather than achieving justice. A dialogue between global health and Buddhism could yield fruitful insights into the nature of suffering, justice, and the relationship between the two.
Three tenets of a peacemaker – Three Pure Precepts
Those who take refuge in the Zen Peacemaker Order vow to live a life of engaged spirituality, guided by three tenets: Not knowing, giving up fixed ideas about oneself and the universe; bearing witness to the joy and suffering of the world; and compassionate action, healing oneself and others.
Although global health practitioners are generally not familiar with the three tenets per se, the principles embodied by the tenets are central to sound global health practice. Not knowing is essential for planning, developing, or implementing any new intervention. All global health students are taught the unfortunate consequences and wasted resources associated with
“solutions” to health problems devised in North America or Europe and “taken to the field” with no local input. The most significant advances in global health are made by those who have intentionally practiced not knowing – spending long periods of time or living with the communities they seek to serve, with no preconceptions, and responding to the direction of the
30 community.
This is exemplified by Drs Abhay and Rani Bang, physicians educated at the Johns
Hopkins University, who returned to rural Gadchiroli, India, to establish the Society for
Education, Action and Research in Community Health (Bang & Bang, 2013). They moved to this impoverished, underserved area and listened deeply, not knowing, to the community as it explored and eventually articulated its own health needs. The priorities for all of their pioneering and highly influential health research are established by the community, not by the Bangs’ own research interests or those of external agencies.
The development of community-directed treatment with ivermectin is another example of the application of not knowing in global health. When ivermectin became available to treat isolated rural communities throughout West and Central Africa for onchocerciasis, an inexpensive, sustainable approach was needed. The practice of not knowing, of listening deeply to community needs, led to the development of community-directed treatment, in which the community – not an international agency or even a national government – decides if the community will participate, who will distribute ivermectin to the community, when treatment will occur, how many distributors will be trained, and whether they will receive monetary compensation (African Program for Onchocerciasis Control, 2012). Not knowing also has contributed to several major advances in global health, made by dedicated young people who either ignored or were uninformed that what they were attempting was “impossible.”
One does not often hear the phrase “bearing witness” in global health circles; to many in global health, it has a rather passive ring, inconsistent with the active, problem-solving orientation of global health. Yet, at a May 20, 2013 conference in Atlanta on global health and hunger, Tom Frieden, the Director of CDC, said that “one of the major roles of public health is to
31 bear witness.” Intrigued by his use of this phrase, I wrote to Dr Frieden, formerly the Health
Commissioner of New York City, to ask if he was familiar with Bernie Glassman. He was not.
As a public health leader, Dr Frieden recognizes the power of bearing witness to shine a light on health inequities, to express and nurture solidarity with those who suffer, and to mobilize resources to transform that suffering.
Global health also is deeply concerned with compassionate action. His Holiness the Dalai
Lama has colorfully highlighted the importance of action, saying that compassion “is not just a wish to see sentient beings free from suffering, but an immediate need to intervene and actively engage, to try to help…According to Buddhist thinking, if a person who has attained stability in his or her compassion training continues to stay in seclusion, that person is not really doing anything with compassion. That person should now be out, running around like a mad dog, actively engaged in acts of compassion” (Davidson & Harrington, 2002).
Global health practitioners tend to place too great an emphasis on the “action” part of compassionate action, on a frenetic effort to heal “the world” without an understanding or awareness of their own inner suffering. When global health leaders met at The Carter Center in
2010, Bill Foege suggested that “consequential compassion” was required for global health, distinguishing it from passive and ineffective compassion, i.e., compassion not linked to action.
This term resonated with those who were present, and it may be a useful vehicle for bringing compassion into global health discourse (Addiss et al., submitted). However, the term does not seem to be informed by current models of compassion from psychology or neuroscience
(Eisenberg, 2002; Goetz, Keltner & Simon-Thomas, 2010; Halifax, 2012; Lutz et al., 2008; Lutz,
Greischar, Perlman, & Davidson, 2009; Klimecki et al., 2012).
I find “consequential compassion” problematic for three reasons. First, compassion does
32 not cling to a particular outcome. One is compassionate regardless of whether one’s compassionate act is “consequential.” The compassion of Mother Teresa for the poor and the dying of Calcutta was arguably of little consequence as measured by indicators typically used in global health. Second, “consequential compassion” implies that one can gauge the veracity of compassion by a measurable outcome. In 2012, Jack Templeton, President and Chairman of the
John Templeton Foundation, pointedly asked me, “If compassion has to be consequential, does the dedicated work of those working on a malaria vaccine, which eventually proves to be ineffective, not qualify as compassionate?” Third, compassion may be most needed, and most difficult, when nothing “consequential” can be done. In such settings, compassionate presence may be much more important than “compassionate action.” Indeed, compassionate end-of-life care has little to do with consequences and everything to do with presence (Giles and Miller,
2012).
Foundational principles of public health
The four foundational principles of public health articulated by Foege and Rosenberg
(Table 2) provide another lens through which we can examine how Buddhist teaching is reflected in, or can contribute to, global health practice. The theme of responsibility is so prominent and central in these principles that one is immediately reminded of Fleet Maull’s teaching of radical responsibility (Maull, 2005). Similar to Maull, global health distinguishes responsibility from blame; taking responsibility is about gazing directly into the face of suffering and accepting responsibility for transforming it.
Their first principle is that “this is a cause-and-effect world; public health takes responsibility for changing those causes that lead to bad effects.” Global health, rooted in traditional epidemiology, has a rather linear, at times almost mechanical, view of causality.
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Somewhat paradoxically, epidemiology relies for its tests of statistical significance on probability theory, which assumes that things happen by “chance,” i.e., without apparent cause.
A dialogue between Buddhist scholars and epidemiologists on causality could be informative. Global health would be challenged by the notions of karma and of dependent co- arising. However, although epidemiologists do not explain events in terms of dependent co- arising, they know from experience that disease outbreaks or epidemics often arise when several factors converge, often in complex, unexpected, or unexplained ways to create the “perfect storm.” I have participated in at least two investigations, one of Legionnaires’ disease (Addiss et. al, 1989) and the other a massive outbreak of diarrhea caused by the parasite Cryptosporidium parvum (Mac Kenzie et al., 1994), in which dependent co-arising aptly describes the complex interplay of human, environmental, microbial, and social factors that manifested at a particular time and place.
The second principle is that “public health takes responsibility for people in the aggregate.” This principle recognizes the interconnectedness of all life, and is consistent with the Buddhist ideal of equanimity. As sentient beings, the health and wellbeing of all of us are inextricably linked. The Bodhisattva seeks enlightenment for all, not just for herself or himself.
The third principle of public health is that it “takes responsibility for the future health of people living now and for the health of people who will live in the future.” This principle, too, speaks to a deep interconnectedness that extends beyond the temporal, which Buddhism acknowledges and celebrates: “All Buddhas throughout space and time, all Bodhisattvas,
Mahasattvas, the great Prajna Paramita.” This principle also speaks to the Buddhist principle of impermanence. The global health decisions that we make now – even as impermanent beings – affect all future generations.
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The fourth principle is that “public health problems constantly reemerge in new forms, and public health takes responsibility for keeping ahead of these changing problems in a changing world.” Again, this principle speaks of impermanence, the continuous process of dependent co-arising, and karma. It also is consistent with the Buddhist notion of non-self, i.e., that self is composed of non-self elements (Thich Nhat Hanh, 1999). Public health problems are not fixed, static entities, but rather are born of relationships and composed of elements that, themselves, are not public health problems. They constantly reemerge in new forms. This principle also speaks to the ideal of prevention, i.e., “keeping ahead of changing problems” based on experience and application of current knowledge.
What can Buddhism offer global health?
Given these parallels and contrasts, what might Buddhism offer the field global health?
First, global health is outward-oriented and results-driven. By nature, it is not particularly reflective. Buddhism can offer global health a conceptual framework, a vocabulary and language with which to encounter, understand, and more firmly embrace its fundamental values of interconnectedness and compassion. Buddhism can provide the spiritual grounding and conceptual clarity that global health needs to become self-aware and to mature as a field and a global movement.
Second, global health focuses on systemic change through programmatic interventions.
By concerning itself with entire populations, global health effectively neglects the individual, and virtually never considers the powerful, some would say essential, role of individual transformation in catalyzing systemic change. This is a significant oversight. Buddhism provides a guide to accessing this power. Individual, inner transformation may be particularly useful when the standard systemic approaches have failed. For example, in San Francisco jails,
35 interventions designed to foster empathy and compassion at the individual level have been shown to dramatically reduce violence and recidivism (Gilligan & Lee, 2005; Lee & Gilligan,
2005).
Third, Buddhism can provide global health practitioners with a framework for experiencing and understanding the non-dual world in which they live, move, and have their being, as well as the skills to see “faces and numbers” at the same time.
Fourth, Buddhism can play a critical role in grounding global health in the daily practice of compassion. The potential for compassion meditation within global health, rooted as it already is in compassion, is substantial. Practices that foster non-referential compassion, i.e., unbiased compassion without a specific object (Halifax, 2011), should be explored in the global health setting to enable practitioners to remain grounded in compassion when working with populations.
Fifth, the spiritual grounding of Buddhism can foster the self-awareness necessary for global health practitioners to recognize how their own “ancient karma” can contribute to unhealthy or shadow dimensions of their desire to “save the world.” It also can clarify and illuminate the relationship between their inner spiritual values and their work, and encourage them to break free of the “taboo of the personal” and create a space in which the sharing of personal stories and the recognition of shared values becomes possible.
Finally, Buddhism can provide an ethical and moral framework (Reilly, 2008) from which to negotiate the complexities of modern global health and to recognize and encounter the forces that act contrary to its core values, such as nationalism, militarism, and greed.
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The Chaplain and Global Health
As a meta-system, the field of global health does not adequately recognize or address the spiritual needs of its practitioners. In this sense, it is not unlike other secular fields of activity in the global sphere, such as business, economic development, or trade. However, global health differs from these fields, both in its core values and in the expectation that its practitioners may be subjected to severe emotional and psychological trauma in emergency, conflict, or refugee settings. This trauma is not unlike that experienced by military personnel. The military has recognized that, in addition to the mental health services provided by psychologists and counselors, chaplains play a crucial role in providing spiritual nurture and support for their troops and helping them find meaning in the extreme situations that they face. In contrast, there are very few chaplains in global health, even among faith-based organizations. The US Public
Health Service, a uniformed service like the military and a major force in global health, with hundreds of employees working in the field, has no chaplains.
My colleague in the global effort to eliminate lymphatic filariasis, Dr Wayne Melrose, is a parasitologist at James Cook University in Townsville, Australia. He also is a reserve chaplain with the Australian Air Force. In May 2012, I asked Dr Melrose about a possible role for chaplains in global health. He responded by contrasting his own experience as an army chaplain in the Middle East with his participation in a public health mission to East Timor as part of his work in global health. As a military chaplain, he was surrounded by a support system that monitored his stress levels, looked after his psychological and spiritual welfare, and provided his family with regular updates. “There was none of this when I was in East Timor. I have no residual trauma from my time in Iraq, but my experience in East Timor still disturbs my sleep.
The human carnage can be worse for the health worker than for the soldier.” Further, he
37 observed that health workers deployed in health missions often work themselves to exhaustion.
“I learned that you have to stop at some point, call it a day, and restore yourself. A chaplain’s role is to help people recognize their limits.”
A core hypothesis of this thesis is that chaplains are needed in global health. The primary focus of their work would be to address the spiritual needs of global health practitioners. In addition, they could play an important role in coordinating and providing spiritual care for the so-called “recipients” of global health care, for example, in refugee or conflict settings, and in building bridges of understanding between global health practitioners and those they seek to serve. Through the spiritual care that they provide, chaplains also can play a critical role in strengthening the field of global health itself.
To explore how a chaplain might address the key spiritual challenges of global health workers and to further define the roles and responsibilities of a global health chaplain, I refer to the tasks and competencies of the chaplain as described by Paget & McCormack (2006) and summarized by eco-chaplain Sarah Vekasi (2013). The four key tasks are: 1) pastoral care; 2) healing; 3) theological support; and 4) catalyzing systemic change. Addressing any one of the four major spiritual challenges in global health, described above, may involve several of these key tasks. For example, helping a global health practitioner who feels disconnected from her work and alienated from those she seeks to serve undertake the “inner work” required for compassion is certainly pastoral care. It also may bring significant inner healing and catalyze systemic change. Further, doing this work in a secular field such as global health requires astute attunement to the theological grounding of the individual practitioner and to global health values.
Although the four competencies of Paget & McCormack (2006) may overlap in practice, they provide a useful framework for outlining the tasks of the global health chaplain.
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Pastoral care
Pastoral care is arguably the most important role for the global health chaplain. My interviews and conversations have convinced me of a prevalent spiritual hunger among global health practitioners and an unmet need for connection, meaning, spiritual grounding, and for the skills needed to sustain a healthy life in the midst of great organizational and interpersonal complexity.
If one is fully engaged in global health work, emotions of despair, grief, anger, and feeling overwhelmed are likely. Few of us have the capacity to face, much less imagine, the enormity of suffering that exists on the global scale. Even fewer, perhaps, have developed the inner awareness and skills required for healthy self-care in the presence of such suffering. As
Rev. Melrose suggests, global health workers need self-care skills as well as “permission” to care for themselves. Chaplains can play a key role in reminding global health practitioners of the truth expressed by Thich Nhat Hahn’s enso: peace in oneself, peace in the world.
The lack of attention to spiritual support is a serious issue of workforce preparedness and sustenance. Many people that I interviewed for this thesis, especially young people early in their careers, express sadness, feelings of burnout, a lack of resiliency, and a loss of meaning and purpose in their work. The effect on productivity, retention, and efficiency has not been measured, but is likely substantial.
Even for those who work mainly behind the front lines, facing computer screens in air- conditioned offices, the spiritual hunger and need for connection is palpable. As Rev. Melrose told me, “It’s similar to military personnel who serve in support roles. All the attention is placed on the soldiers on the front line and those in support roles feel less connected to the mission, less
39 important. My job as chaplain is to tell these people that they matter, that their work is important and makes a difference.”
To provide pastoral care, the global health chaplain must be able to assess the spiritual needs of individual practitioners and to offer counsel or make referrals as appropriate. He or she must be familiar with four major spiritual challenges in global health: non-duality; compassion; the taboo of the personal; and the compulsion to “save the world.”
Non-duality
As noted above, global health practitioners have a highly dualistic worldview, based on their scientific training and institutional cultures. However, they also have a lived experience of non-duality, of which they are only vaguely aware, and the statements of a few of their leaders, such as Bill Foege, which seem to suggest that the field requires non-dual awareness, i.e., “faces and numbers.” Reconciling a dualistic worldview with non-dual experience can be a challenge, for which practitioners may seek pastoral care. The global health chaplain can offer a spiritual framework that acknowledges and affirms the non-dual, guidance and resources for the personal experience of non-duality, and a language for exploring and articulating the importance of non- duality in one’s life and work.
Compassion
Given the importance of compassion in global health, helping those in the field to understand, experience, and re-connect with their compassionate impulse may be the most critical role of the global health chaplain. As noted above, some global health practitioners have little personal contact with the human faces of the suffering they are working to relieve or prevent; for them, emotional resonance may be inadequate for compassion. For others, feelings of helplessness in the presence of enormous suffering may be overwhelming, and they act in a
40 way to relieve their own emotional distress. In addition, global health workers have a tendency to identify strongly with the potential of their programs to relieve suffering, and cling to specific outcomes, which must be quantifiable and robust enough to justify further funding from the donors. Helping global health practitioners understand compassion at a deeper level and engage in the inner work of compassion is an essential role of the chaplain.
Recent neuroscience research has confirmed the powerful effects of training in compassion mediation (Klimecki et al., 2012; Lutz et al., 2008). To my knowledge, this has not been explored in the global health setting. Non-referential compassion practices may be particularly fruitful in global health, where practitioners may be separated by great distances from those they seek to serve and where the emphasis is on the health of populations, rather than individuals. Again, the ability to see “faces and numbers” is a critical skill for global health.
Both are needed for compassion in the global health context.
Taboo of the personal
As part of their pastoral care, global health chaplains can provide ‘safe’ space for individuals and groups to explore the deep connection between their own spiritual values and their work in the world. He or she can affirm the importance of compassion and allow global health workers to bring a more complete human presence into their work. The chaplain can encourage global health practitioners, collectively, to reflect on and share their own personal stories. Invariably, these conversations are deeply moving. The sharing of personal stories, often never before revealed, holds tremendous power to motivate, shape, and sustain compassionate action. Rarely is there an opportunity to follow up and nurture the personal reflection that these rare opportunities generate. To do so would be the work of pastoral care.
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Saving the world
The skilled chaplain also can help global health practitioners deal with the subtle shadow side of their calling to the field, their compulsion to “save the world.” The overwhelming human needs in global health make this particularly challenging. The chaplain can help practitioners become aware of the role of ego and identity, and to understand how over-identification with work can affect other areas of their lives.
Healing
As with other healing professions, those who enter global health may be “wounded healers.”
The challenges of working in this field, where specific interventions often seem to have little impact on the immensity of human suffering, can exacerbate these wounds. The global health chaplain offers healing through the gift of presence (Harper, 1991) and through skilled pastoral care. In addition, he or she should have training in healing trauma, or at least be able to recognize post-traumatic stress disorder and make an appropriate referral. The chaplain should recognize the symptoms of burnout and be able to provide support that will foster the restoration of resiliency.
One of the most important healing functions of the chaplain will be to help global health practitioners reconnect with their own spirituality, which for many, was foundational for their entry into the field in the first place. Spiritual practice is often left behind in the pressures of global health practice and the incessant drive for action and measurable outcomes. Deep healing is possible through the rediscovery and nourishment of one’s spirituality.
Finally, the chaplain can bring healing through facilitating the restoration of relationships that have been damaged by the tendency of global health practitioners to over-identify with their work and their compulsion to “save the world.”
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Theological support
For faith-based organizations engaged in global health, religious rites, rituals, and ceremonies provide a great source of meaning, comfort, and connection for practitioners, especially when faced with loss of life or responding to extraordinary suffering, as with natural disasters, violence, or refugee situations. Chaplains play a critically important role in such organizations by leading religious services and offering prayers, both during times of great challenge and in moments of celebration and gratitude.
Most global health settings are secular, involving practitioners of different faith traditions or no faith at all. Theological support, broadly defined, is no less important in such settings, particularly given the universality of compassion in all religions and its foundational importance to global health. Rituals or ceremonies are needed that allow practitioners to reconnect with their own spirituality and sense of compassion, which provide a sense of meaning and context for the work to which they have devoted their professional lives.
This is especially true when collective grieving is required. Rituals are needed for the collective sharing of tragedy – as when polio workers in Pakistan were killed recently in an attempt to disrupt and halt the vaccination effort, which was seen by the perpetrators as an imposition by Western powers. In global health settings, such loss may be observed by a moment of silence, followed by reflections in memory and honor of the one whose life was lost.
Several years ago, when one of our Haitian colleagues, a young man with tremendous promise and integrity, was murdered in a slum of Port-au-Prince, such silence was all our devastated team at CDC could muster in the immediate aftermath of his death. We sorely missed the presence of a skilled chaplain who could have held the space for us to grieve together.
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The chaplain also can help those in global health come to terms with unintended harmful consequences of their actions or policies. Apology for medical errors and misadventures has become more commonplace in medicine (Wood & Star, 2007) in recent years. Unfortunately, apology is still a rarity in global health. Global health does not have a tradition of honoring or publicly acknowledging those whose lives are lost as a consequence of well-intended interventions, as happened when mass treatment with ivermectin, intended to prevent blindness due to onchocerciasis, was associated with the deaths of those who happened to be heavily infected with the African eye worm parasite, Loa loa (Twum-Danso, 2003). The lack of memorial ceremonies in such cases makes it more difficult for practitioners to come to terms with what has happened. Thus, chaplains could help global health practitioners grieve loss and apologize for harm, both of which are necessary for inner healing and restoring of relationships.
Change agent
Providing pastoral care to individual practitioners can help individual practitioners rediscover their own spirituality. Pastoral care in this setting also bears witness to the spiritual foundations of global health as a field. As change agents, chaplains can create a culture of
“permission” for practitioners to explore privately and speak publicly about the compassionate core of global health. Such a dialogue within global health is essential to restore integrity and moral clarity to a field that has been compromised by the forces of fear, profit, nationalism, and militarism. By bringing a much-needed prophetic voice and moral compass to the field, the chaplain can help global health resist the erosion of its spiritual values and prevent the distortion of public health into civil defense. The voice and witness of the chaplain are needed to keep global health ‘honest,’ grounded in the realization of interconnectedness. The chaplain also can encourage and support global health leaders and practitioners in “making the right people
44 uncomfortable” so that those with the power to allocate resources and set health policy do so properly.
Direct service to ‘recipients’ of global health
In addition to serving global health practitioners, chaplains also have important roles to play in the field, working directly with the so-called “recipients” of global health. Especially in chaotic situations of armed conflict, natural disasters, or refugee resettlement, the chaplain can serve as a liaison between expatriate workers and local communities, work with local clergy to identify spiritual needs and organize spiritual care, and challenge global health providers when their actions violate the dignity, cultural sensitivities, or religious values of those they intend to serve. Chaplains bring to such situations much-needed skills in mediation, conflict resolution, and communication.
The Buddhist Chaplain in Global Health
The diverse faith traditions of global health practitioners and the largely secular nature of the field suggest that global health chaplaincy is likely to require an interfaith approach.
However, Buddhist chaplains may be uniquely suited to address some of the most critical spiritual needs of global health practitioners. First, Buddhist chaplains can provide global health practitioners with a framework and practices for experiencing and understanding non-dual reality, to enable them to see “the faces and numbers” at the same time. Second, Buddhist chaplains can offer guidance in the daily practice of meditation, facilitate awareness of inter- being, and help practitioners move into a deeper understanding and practice of compassion.
Third, Buddhist chaplains can share the rich insights of Buddhist psychology to encourage practitioners to examine the potential shadow aspects of their extraordinary commitment and
45 drive. Fourth, Buddhist chaplains with training in systems theory can help practitioners understand and address some of the complex forces that threaten the core values of global health.
Finally, the Buddhist chaplain, grounded in the three tenets of Engaged Buddhism can offer the extraordinary wisdom of not knowing – essential for developing sound, sustainable, global health programs that address local concerns; the inner strength required to bear witness to the immense suffering of the world; and the capacity for sustained, truly compassionate action in the midst of unimaginable complexity.
The Buddhist chaplain can help transform global health through the transformation of its practitioners and the clarifying of its values. The chaplain can enable global health to realize its potential and, in the words of the late street performance artist Steve Ben Israel, to “foment a mass uprising of compassion” (Vitello, 2012).
Lay Buddhist chaplaincy in global health
As I began to explore my own potential role in global health as a lay Buddhist chaplain, I realized that while this term usually refers to a full- or part-time chaplain who is ordained as a lay person, rather than as a Buddhist priest, (i.e., lay modifies Buddhist), it also means, for me, an ordained Buddhist who seeks to serve as a chaplain while making a living as a global health practitioner (i.e., lay modifies chaplain). More specifically, in my case the term lay would modify both Buddhist (i.e., not a priest) and chaplain (i.e., not employed as a chaplain). Some in the Christian tradition would refer to the lay chaplain in this latter sense as a “tentmaker”, after the apostle Paul, who earned his living making tents rather from his work as a religious leader.
With no office of chaplain yet established in global health, the Buddhist global health chaplain will be a tentmaker, at least for now. This raises the question as to the where the role of chaplain is currently found within global health organizations. Chaplaincy, where it exists, is
46 dispersed throughout organizations that neither recognize the need for it nor understand its importance. The role of chaplain currently is assumed by individual practitioners who, in addition to their official duties, offer encouragement, effect healing, and work for structural change, generally unheralded and largely unnoticed.
Thus, within global health, chaplaincy is not yet located within a single office or person, but rather dispersed among many tentmakers who do not necessarily view themselves as doing chaplaincy work. During his tenure as Surgeon General, the late C. Everett Koop arguably also took on the role of Chaplain General for the US Public Health Service. Tentmaker chaplains understand and personally experience the spiritual challenges of global health and can bring that understanding and solidarity into their chaplaincy work. On the other hand, their chaplaincy work is necessarily limited in scope, as they are neither endorsed nor compensated as chaplains by the organizations in which they work. To successfully navigate the tension between their official duties and their vocation as a lay chaplain requires sensitivity to the needs of their colleagues; an open, humble, unpretentious attitude; a deep understanding of organizational culture; and an awareness of their role within it.
Conclusion
Global health is rooted in spiritual values, which, to a large extent, it shares with
Buddhism. Compassion and inter-being are among the most important. The complex, global, outcome-driven, science-based characteristics of global health give rise to four key spiritual tasks or challenges. These include: 1) experiencing and negotiating the fundamental non-dual nature of global health; 2) understanding and working through the barriers to compassion at inner, interpersonal, and organizational levels; 3) breaking the taboo of the personal and
47 acknowledging, both individually and collectively, the importance of spirituality as a foundational source of global health; and 4) becoming aware of the motivations and shadow aspects of one’s dedication to, and identification with, the field.
My interviews and conversations with global health practitioners suggest that these spiritual challenges are inadequately addressed. Consequently, many practitioners suffer – mostly in silence – and along with them, the field of global health itself and those it seeks to serve. To transform this suffering, chaplains can offer pastoral care, healing, and theological support and serve as agents of change.
A deeper understanding and exploration of the spiritual underpinnings of global health is needed. Buddhism offers a promising conceptual framework as well as rich experiential resources, which could be particularly applicable to global health, given the similarity of their core values. With the unprecedented economic, technologic, and human resources now available both to heal and to harm on the global stage, it seems rather strange, and somewhat worrisome, that spiritual formation, broadly conceived – not to mention mere conversation or sharing of personal stories – is not an essential part of global health training. In the absence of such formation, it is no wonder that so many global health practitioners feel adrift from their spiritual moorings.
A dialogue between Buddhism and global health would have direct relevance to several other fields that have been similarly transformed by the forces of globalization. The spiritual challenges of global health practitioners are likely to be similar to those for workers in other fields, such as international development or economics. In addition, what compassion means and what action it requires in an age of globalization is an emerging issue for religious and spiritual communities (O’Connell, 2009). The Buddhist chaplain, with a deep understanding of suffering
48 and inter-being, grounded in compassion and non-dualism, can provide much-needed spiritual guidance and support for individuals in these fields and facilitate structural change in the complex, dynamic, global systems in which we now live, move, and have our being.
49
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Table 1. Characteristics of public health, international health, and global health. Adapted from Koplan et al., 2009.
Characteristic Public health International health Global health
Geographical focus Particular Countries other than All people – can community or one’s own, especially transcend national country low- and middle-income boundaries
Cooperation required Does not usually Usually requires bi- Often requires to develop and require global national cooperation global cooperation implement solutions cooperation
Prevention in Primarily prevention Embraces both Embraces both populations or programmes for clinical care for populations individuals? Objectives for health Health equity within Seeks to help people of Health equity equity and access a nation or other nations among nations and community for all people
Range of disciplines: Emphasizes Has not emphasized Highly Interdisciplinary and multidisciplinary multidisciplinarity multidisciplinary multidisciplinary? approaches, within and beyond especially within health sciences health and social sciences
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Table 2. Foundational principles of public health, as articulated by Foege and Rosenberg (1999) and related principles in Buddhism.
Foundational Principles of Public Health Buddhist Principles 1. This is a cause-and-effect world; public health takes Karma; radical responsibility responsibility for changing those causes that lead to bad effects. 2. Public health takes responsibility for people in the aggregate. Interconnectedness; radical responsibility 3. Public health takes responsibility for the future health of Interconnectedness; people living now and for the health of people who will live Bodhisattva in the future. 4. Public health problems constantly reemerge in new forms, Impermanence; dependent co- and public health takes responsibility for keeping ahead of arising. Self is comprised of these changing problems in a changing world. non-self elements.
Figure 1.
A Social Psychology Model of Compassion
Empathy Motive Behavior
Compassion Selfless Not • Cognitive Sympathy Desire to transform pro-social attached attunement suffering to behavior outcome (perspective- Yes Empathic taking; stability Arousal Emotional of mind) Regulation “Selfish” • Emotional pro-social No attunement behavior • Memory Personal (personal Distress Fight (moral outrage) experience) Flight (avoidance, abandonment) Freeze (numbing) Adapted from Halifax, Batson, Eisenberg, and others