Teaching spirituality to humanitarians.

It is widely accepted that humanitarians should undertake a course on ethics and human rights before and after a humanitarian mission to low/middle-income countries (LMICs).

However, the teaching of religion, spirituality, social justice and morality is generally not included in the ethics courses.

There is a bidirectional relationship between spirituality and social justice.

Connectivity via the internet and mobile devices has enabled people and healthcare workers in the Global South to become aware of social, moral and cultural issues in the Global North.

Humanitarians should engage with their counterparts in LMICs on controversial topics of social justice, both in the Global North and South, even if they are not directly connected with their work.

The holistic nature of public health should be emphasised so that humanitarians can integrate culture, religion, morality and spirituality through the lens of global health.

Introduction

There is an increasing interest in humanitarian missions in medical institutions in high-income countries (HICs). It is now widely accepted that humanitarians should undertake a course on ethics and human rights before embarking, and debriefing after, humanitarian missions to low/middle-income countries (LMICs).1 2 However, the teaching of religion, spirituality and morality is generally not included in ethics courses.

It is now recognised that religious and spiritual concerns are important for understanding health-related behaviours and sources of social support to patients, which makes it important for humanitarians to appreciate and understand these nuances in their work.3 Religious institutions and clergy, both in HICs and LMICs, often function as gatekeepers for individuals seeking healthcare, particularly mental health, among poor and disenfranchised populations.4 Religious practices and moral codes vary widely in different parts of the world which may affect both the humanitarian and recipient of global health. In addition to religious beliefs and moral codes, the younger generation of healthcare workers, both in HICs and LMICs, have increasingly adopted spirituality and metaphysics. Humanitarians travelling from HICs to LMICs may face questions regarding their practices of meditation, yoga, mindfulness, and spirituality which may cause conflicts within themselves or in their dealing with their counterparts and the population seeking their attention in LMICs.

Humanitarians, who in the past, avoided contentious topics such as child marriage, genital mutilation, female infanticide, structural racism and white supremacy in Western medicine5 in their interaction with their counterparts in LMICs, should be prepared to debate these through the lens of compassion and spirituality, even if they are not directly connected with their work.

I propose that a course on anthropology to include religious and spiritual practices, and moral codes of the population of the host country be included in the pre-departure briefing of humanitarians. A grounding in spirituality could provide a robust ethical and moral framework that may help humanitarians to negotiate the complexities of structural racism, nationalism, militarism and greed.6

Religiosity and spirituality

Religion is generally defined as a set of beliefs, rituals and practices embodied within an organisation. Spirituality, on the other hand, is thought of as a search for what is sacred in life, one’s deepest values, along with a relationship with God, or a higher power, that transcends the self. Persons may hold powerful spiritual beliefs, and may or may not be active in any institutional religion.7 Many people who may not be religious in the traditional sense admit to a sense of ‘reverence’ and ‘spirituality’ for life, a concept proposed by Nobel Prize winner humanitarian Albert Schweitzer.8 Jeff Levin, professor of epidemiology and population health at Baylor University, posited, “A lot of people may not be institutionally religious in the same ways they have been, but as far as their own private practices and beliefs, they are still very engaged. It still remains a very spiritually involved country (United States) one way or the other.”9 In a prospective, self-administered questionnaire in general and orthopaedic surgical outpatients at the University of Alabama, the majority of patients agreed that surgeons should be aware of their patients’ religiosity and spirituality; 63% concurred that surgeons should take a spiritual history, and 64% indicated that their trust in their surgeon would increase if they did so.10

Morals and ethics

The term morals is derived from the Greek word ‘mos’ which refers to custom, and the customs are determined by a group of individuals or some authority.11 Morals are the social, cultural, and religious beliefs or values of an individual or group which tell us what is right or wrong. They are the rules and standards made by the society or culture which are to be followed by us while deciding what is right. Some moral principles are: do not cheat, be loyal, be patient, always tell the truth, be generous. Morals refer to the beliefs of what is not objectively right, but what is considered right for any situation, so it can be said that what is morally correct may not be objectively correct.12

Ethics originated from the Greek word ‘ethikos’ which refers to character, and character is an attribute.13 Ethics refer to rules provided by an external source, for example, codes of conduct in workplaces or principles in religions. It works as a guiding principle to decide what is good or bad. They are the standards that govern the life of a person. Ethics are also known as moral philosophy. Some ethical principles are truthfulness, honesty, loyalty, respect, fairness and integrity—which we have applied in our humanitarian missions.14

New era of moral dilemmas for humanitarians

As we enter the global humanitarian arena on a wider scale, new issues challenging our views of morality and ethics will certainly present themselves. These include, but are not limited, to the sexual harassment scandal in OXFAM,15 a worldwide humanitarian organisation, and genocide in Myanmar.16 Should institutions and individuals work with such organisations, or in these countries, where human rights are routinely violated or shun them? An argument could be made for either position; engagement to bring about a change or shun them to enforce change—a decision based on a person’s beliefs and conscience.

Our own experience illustrates the moral versus ethical dilemmas in our humanitarian work. High net worth Guyanese individuals and politicians generally travel to the USA for treatment even for those procedures that are performed routinely in Guyana. Jindal’s team does not perform surgical procedures that are done by the local surgeons, so as not to take away their source of income. In course of their humanitarian mission, a well-known politician approached the team to perform a routine cataract operation, which would avoid him the inconvenience of going to the USA. This posed a dilemma for the team on whether to operate or supervise the local surgeon. Jindal’s team eventually operated on him as the team felt that positive publicity generated by operating on a well-known local politician would help the mission in the long run.17 Another illustrative example is that the benefactor of the author’s humanitarian mission to Guyana is an Indo-Guyanese living in New York. He was forced out of Guyana as a young child due to a brutal dictatorship by an Afro-Guyanese. The population of Guyana is evenly divided between those of African and Indian (originally from India) heritage. At the beginning of the mission in 2007, he wished that our efforts are directed ONLY towards the ‘Indian’ half of the population. This policy would produce an inequitable result. Jindal’s team was able to convince the benefactor that adherence to our legal and moral code would produce a more sustainable outcome by providing care to all eligible patients, regardless of their ethnicity.18

Incorporation of religion and spirituality in global health

As a concept, it is now recognised that religion is an integral part of public health and human rights19 as all major religions assert that everyone ought to have essential food, water, clothing, shelter, and security in the category of economic, social, and cultural rights. Humanitarian missions often depend on funding from organised religion such as the Christian ‘tithe’, the Sanskrit concept of ‘dāna’ (cultivating generosity) or ‘zakat’ (alms giving). Many humanitarians view their work as seva—a service that is performed without any expectation of result or award for performing it. ‘Seva is an ancient Sanskrit term, which originally referred to the service performed by members of the community’.20 These funds often enable humanitarians to carry out global health activities, however, it must be acknowledged that religion may not be a neutral force and on occasions can be toxic, with partisan attitudes toward gender and suffering; health policies; and ethics and law. If humanitarians belong to a particular faith, it behoves on the global health community that we should be sensitive to the people at the receiving end of their largesse.

Addiss carried out informal interviews with more than 300 global health leaders, students, and practitioners to study spirituality in global health practice and identify factors that influence and limit its expression. Four spiritual themes were described: compassion at a distance; dichotomous thinking; a conspiracy of silence and compulsion to save the world. Practitioners expressed strong interest in bringing spirituality more fully into global health discourse, which could help the field realise its potential.21 An interesting finding of this study was ‘excessive self-identification with the righteousness of one’s cause’ which could potentially contribute to an inability to come to terms with unintended harmful consequences of one’s actions. It was also pointed out that humanitarians avoided publicly acknowledging adverse outcomes; a good example is when mass treatment with ivermectin, intended to prevent blindness due to onchocerciasis, was associated with the deaths of those who were heavily infected with Loa loa.22

On occasions, religious communities making donations in the form of goods or human capital often have moral positions that are contrary to the broad goals of public health. Religious opposition to contraception and religious support of child marriage or genital mutilation are just some examples of this challenge.23 There is a need to foster a deep understanding of the religious and moral codes and practices to avoid sectarianism. Humanitarians must also acknowledge that on occasions, people residing in the Global South may wish to continue with practices which may be abhorrent to current norms in the Global North; however, these may have benefits for the group (eg, it strengthens existing social relations or ensures the continuation of family lineage).24

Spirituality and social justice in global health

It has been hypothesised that there is a bidirectional relationship between spirituality and social justice. Powell viewed global health as a pursuit of social justice and indirectly linked to spirituality.25 The core of global health is to relieve suffering in LMICs with emphasis on accountability, such as the Cochrane Global Mental Health with a focus on interventions that fit with the public health approach in addition to traditional biomedical approach with emphasis on contributions from LMICs.26 27 Therefore, global health has attracted students from a wide spectrum of disciplines including those from theology and religion. The political beliefs of the governments in the Global North have to be considered28 which can conflict with compassionate action, however, it can be argued that humanitarians have to confront these issues by debating their partners in the Global South to the values that unite them, such as social justice and compassion, rather than political leanings of the funding agencies.29 I suggest that humanitarians should consider spirituality as part of a patient’s cultural identity, which would enable practitioners to provide holistic, patient-centred care in day-to-day clinical practice in LMICs.30

Conclusion

I believe that it be should be mandatory for humanitarians to familiarise themselves with the religious, moral, and spiritual practices so that they can relate to their colleagues and population in the LMICs. There is a need for a scenario-based tool that can be used in pre-departure training to work through anticipated dilemmas when ethical or moral issues arise, or in debriefing sessions after challenging decisions. A briefing on religious and moral practices in LMICs could be given by sociology, religious leaders in class or remotely. The holistic nature of public health should be emphasised so that humanitarians can integrate culture, religion, morality, spirituality and health primarily through the lens of global health. Humanitarians have to be prepared for scrutiny of their beliefs when they come across deep moral dilemmas such as child marriage, genital mutilation, female infanticide or structural racism, even if they are not directly connected with their work.