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From Luke’s Journal February 2024 | Vol.29 No.1 | Missions and Sacrificial Service

It is now over ten years since we first set foot in the beautiful part of the world known as Central Asia, and we remain involved with both ongoing work from a distance and also work on the ground (two trips in 2023).

Sacrificial service is part of the calling of all believers (Heb 12:2, 1 Pet 1:6-7), so working in mission work overseas has to be seen as part of the bigger picture of believers and one where it is important for each person to know their specific calling.  I do not see this as being superior to work at home but if you are called to work overseas cross-culturally, then God will enable you to do this effectively. 

The call to work overseas came about the time that Fay and I married.  It was very clear to us both that we were called to service overseas.  There was no given timeframe but it was specific.  While it took us years to get there, it is now in hindsight that we can see how the work we had in the intervening years prepared us so well for the work we are still involved with.  In Central Asia, older clinicians are given more respect and listened to more, and experience is of great value as the clinical work is often challenging.  We were both in our late fifties by the time we went, waiting till our youngest was at university and so not totally dependent on us.  Having worked in New Zealand and Australia as a consultant paediatrician for over twenty years, it was seen by our peers as a bit different or odd to choose overseas work in a poor country at that time of our careers.

Altogether, eighteen months elapsed from the time of being accepted by the sending organisation until we got there.  What preparation was needed before we left? Here are some of the many issues we were aware of as we made these choices:

Superannuation would cease

Many people look on the last years of work as the time when you prepare for your retirement.  Our existing funds were placed with a financial advisor and were looked after in our absence.

Family and  friends

We left our immediate family who, while supportive, were upset about our leaving.  Over the coming years, our younger two children got married and five grandchildren were born.  Thankfully, we were able to manage to attend the weddings and Fay was able to be around to assist at the time of some of the births.  Although we missed our youngest daughter’s graduation, friends were able to attend on our behalf and the increasingly-efficient internet allowed us to watch her graduation online.  Internet access also allowed us to talk to family on a regular basis.  The time difference of only four hours made this relatively easy to manage.  These are inevitable issues of working a long way from home.

Medical registration

In order to keep up my medical registration in Australia, I worked about four weeks a year in Australia.  This fortuitously also funded much of our support.  It was not possible to be registered where we were working as they have no registration board. I learnt, over time, that local doctors get a licence to practise from the local head doctor and this is their system, but it does not meet the requirements of Australian registration.   Much of my Australian locum work was in outback Queensland.  Our sending agency was supportive of this but, unfortunately, it meant additional travel time, amounting to around twenty hours on planes each trip.  It did not seem to be such a big issue initially, but as time went on it became more tiring for both of us to spend so much time in airports.

Different medical systems

One of the biggest challenges is moving from the comfort of a medical system which you know and can navigate, to one which is very different, more complex and has a different set of norms. The poor medical education system followed an Eastern European way, providing only didactic lectures, with graduates not learning clinical medicine until after graduation.  They had few problem-solving skills, along with regimented ways of doing things, following protocols which, in many cases, had major errors in them. 

Doing what you were taught and following guidelines out of fear of doing something wrong is very much the usual way of practice. The ability of doctors to look up information is limited and the ability to read articles, assess information and modify clinical practice accordingly is low.  The available medical literature in the local language is limited.

The health literacy of patients about medications and how to take them correctly is also limited: when changing a young man’s anticonvulsants to a more appropriate regimen, we wrote down instructions for the mother to do the change over two weeks.  The mother decided to do it over three days (“Why wait two weeks?”) and the young man slept for two days but woke up much better!  This sort of thing was a little nerve-wracking and challenging to cope with.  Thankfully, this young man did much better on the changed medication as we had expected.  These sorts of incidents challenged us since we did not know what might have happened if things had gone wrong. Nevertheless,  we were there and asked to assist, so we did our best in the circumstances. 

“Early in our time, there were many practices that we had to ignore otherwise we would have gone crazy.  We had to focus on the things we could change and the outcomes we were seeing in our own work and ignore the rest.”

Early in our time, there were many practices that we had to ignore otherwise we would have gone crazy.  We had to focus on the things we could change and the outcomes we were seeing in our own work and ignore the rest.  We suspect that the morbidity and mortality from many of their practices was high.  However, this is their system, and we are only guests within that system. I think it took about two years before we had credibility within their system.  Then we were able to make more changes, but it took time and patience.  Coming back to Australia and working within our health system reinforces the value of the system we have and how good and accountable it is.

Peer support 

Another aspect of this is that as you practise medicine you develop comfort working within a system that you know and have colleagues whom you can consult with.  You develop your skills as you practise.  When you move to a new place, you lose this and have to come to terms with a very different place, a different language and different ways of seeing things in medicine.  You have to learn to see how people understand what they see and understand medicine as it is practised in this new environment. You often do not have colleagues that you can consult easily and you may very much have to rely on your own clinical judgement, often without reliable laboratory tests or organ imaging.  As time goes on, you may be able to establish relationships with other medical professionals that can support you, but this may not always be possible. 

Having access to reliable internet and the international medical community has been very helpful, enabling complex cases to be discussed with others in Western countries and assisting with diagnoses being made.  Professional isolation is nevertheless a challenge.  I remember thinking more than once, “Is there another new thing to learn here?”  You think you are making progress in understanding their system and getting used to it and then you are stumped by something different or new that is a challenge. 

One aspect of this was seeing children who had been burnt by a witch doctor supposedly because they had big heads.  Their heads were of normal size but they had burns on the sides of their heads made by red hot stones. Another child had received multiple razor blade cuts to his back and it had healed in a pattern resembling a woven garment.  My simple advice to parents was to avoid the witch doctor as I saw no benefits from anything he did. A week or so after this event, I had severe shoulder pain and one prayer partner emailed to say the witch doctor was getting back at me.  We prayed and the pain disappeared immediately.

Challenges of teaching and training

As time went on, there were and still are opportunities for training and teaching.  It took a while to realise that for teaching to be of value it must engage the trainees.  While lectures are needed, there must also be case examples for the trainees to solve and opportunities for them to present.  A history of didactic learning combined with a shame-based culture did not easily allow for the questioning of cases presented by other doctors, particularly if they were more senior.  In order to overcome this, we have either presented cases ourselves, or asked the trainees to present cases and then discussed them together.  This has been challenging within their system but has proved of great benefit. 

Comfort levels for living

We lived very well in both apartments and houses and had our own car which was necessary for work.  However, many mundane logistics took a lot of time: like paying the yearly car tax.  Although only $30, it could take half a day to get all the paperwork done and the small amount paid.  When doing outreach clinics, we often stayed in places where we slept on the floor, or had shared facilities which were outside.  Long drop toilets remain the norm in most rural areas and even for staff in some hospital and clinic locations.  On two occasions we were the first westerners to stay in the hotel accommodation.  We always had hand wipes and endeavoured to have our own water supply.  This was usually not too difficult to manage as it was cheap.  Winters were cold and summers sometimes quite hot and we did many outreach clinics in the spring and autumn to avoid the extremes of seasonal climates.

Cultural expectations

In a culture where relationships are paramount, taking time for tea is essential.  On more than one occasion, I thought I could just present a report after completing some work.  Though the report was important, taking time for tea and to discuss the report in person was more important.  You had to make time for lots of tea.

Corruption

Corruption remains a big issue in poor countries. While there is much being done to reduce it, you had to learn how to manage it and be clear.  When I got speeding fines even though not speeding, I just paid up and did not contest.  It may have meant that the cops made money illegally, but it was also a way of getting on with life there.  We did make it very clear when dealing with monies that we did not pay bribes and if anyone we were dealing with was engaged in bribery or corruption, then we would not continue to work with them. This was respected, but often challenged. 

Adaptation

There were many differences in both life and work.  To survive, the onus was on us to adapt.  This was a challenge, and part of the process of becoming effective and being able to survive and thrive.  It was a necessary part of the changes we needed to make to be there: giving up our norms and comfort zones and adapting to be in the place of service.

Renting our house

We had lived on five acres of land before leaving.  Although we tried to sell it before we left, this did not occur so it was rented during our absence.  It needed significant upkeep over the time with various repairs needed.  On our return, the garden needed much attention and, after taking thirty trailer loads of green waste to the transfer station, we eventually invested in a chipper!!  It is good to retain a home to return to when full time work does finish, but the place will not be the same when you return, and you have to adjust to the need for repairs and upgrades.

Then there are other things that happen as you embark on a long period of overseas work:

Support of others

One of the many things that happens when you embark on a time of service work is that you develop friendships and become enmeshed with families and their lives overseas. For us, this developed into supporting one family longer term. This is inevitable when you embark on longer term work and when you return home, it is one of the things you have to continue to manage, and while good internet access makes keeping contact relatively easy, it does not replace person to person engagement. We have had requests for visits that have not been possible but internet WhatsApp calls are certainly very helpful. You find you live in two worlds, and there are often conflicts due to the differences in lifestyles between the two places.

These are some of the very practical things that have occurred over the time away and even now we continue to do work remotely each week. This week we have completed another grant application.

“On our return, we have been asked, “Was it worth it all?”  The answer is a resounding YES! It has been an amazing time of learning, being part of a different community and culture, and being able to assist in bringing about national change to improve child health and reduce disability. “

On our return, we have been asked, “Was it worth it all?”  The answer is a resounding YES! It has been an amazing time of learning, being part of a different community and culture, and being able to assist in bringing about national change to improve child health and reduce disability.  In addition, there have been opportunities to assist in writing national health policies, work with parent groups and engage in training at the national children’s hospital and other major health facilities.  One thing we learnt along the way was that we needed to engage local doctors and health professionals in the training, and have done this using case studies and in getting local staff to present cases for discussion.

When we were finishing our full time work, we had opportunities to see some of the people we had lived and worked with over time. Their feedback was encouraging and supportive of the work we had done.  Our local pastor said that as professionals we demonstrated the gospel in the way we lived and this was so helpful to him.  He said that his country did not need more evangelists since there were local people who could do this.  More necessary were professionals who put their faith into practice in their professional roles, showing care and compassion that people respond to, which in turn assists the local church.  One of the people at a national organisation I worked with said that the country was changed forever because I had loved the mothers of children with disabilities and given them their dignity back.

Sacrifice is part of being a believer and is worth every bit. Being called means you will be enabled to do what you are called to.  For those who are not called to work cross-culturally, it is important to be connected to those overseas, supporting them both in prayer and financially if able.  This is all part of missional service. 

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