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ss nucleus - winter 1998,  Health, Poverty and Developing World Debt

Health, Poverty and Developing World Debt

The developing world is still a popular destination for medical students on electives. Some are drawn by the chance to experience a new country and a different culture. Others go because of the opportunity to get 'hands on' experience and still others to test a 'calling' to future work in the developing world. It is easy during these brief visits to get the impression that the health of the populations in these countries is gradually improving; that the world is becoming a 'better place' to live in. But did you know that:

  • In sub-Saharan Africa improvements in health have reversed in the past two decades.[1] Average life expectancy is only 51 years and malaria and TB are increasing.[2]
  • In parts of central, southern and eastern Africa 30-40% of pregnant women are now HIV positive.[3]
  • In 1988 nearly 46 million women delivered without the assistance of trained personnel, the majority of these women living in the least developed countries.[4]
  • Of the 50 million deaths occurring annually in the world, about 15 million are children under the age of five years.
  • World-wide, four million children die every year from acute diarrhoea and four million from respiratory infections, both treatable conditions.
  • Three million children per year die from the immunisable infections poliomyelitis, tetanus, measles, diphtheria, pertussis and tuberculosis.[5]
Why this continuing loss of human life? Why is the situation getting worse despite advances in medical understanding and technology?

Poverty and health

There are many reasons why measures of health in the developing world are getting worse, but as a group of medical doctors working in public health recently put it, 'the number one health problem is poverty. For the poorest countries, the health sector alone cannot ensure better health even if it were able to function at maximum effectiveness. We have to accept that we can no longer deal with health while ignoring poverty.'[6]

It is a lesson that the modern Western medical world has forgotten. We have become obsessed with acute, intensive, super-specialised medicine whilst forgetting that clean drinking water, proper sanitation, adequate nutrition and good education have over the years saved far more lives than any single medical technology or treatment. The sanitary engineers and health reformers of 19th century Europe did more to reduce mortality than any doctor ever will!

The WHO's annual report in 1995 testifies to this. It states that poverty was the main reason that babies weren't vaccinated, that children caught dysentery from infected water supplies, that drugs and other treatments were not available and that half a million mothers died unnecessarily in childbirth.[7]

But surely poverty has been lessening over the last few decades as the world has become a global economy of free trade. Or has it?

In fact, the reverse has happened. The number of people living in absolute poverty (earning less than US $70 a year) has more than doubled since 1975 and now stands at 1.3 billion.[8] Seven out of ten of these are women.[9] By the end of the decade two thirds of Africans will live in absolute poverty, more than half still lacking safe water and 70% without proper sanitation.[10]

Why is this so? The legacies of colonialism, economic mismanagement, war and corruption have all played their part in weakening developing world economies. But one huge factor has been the need for already bankrupt countries to repay debts owed to developed world banks and nations.

The international debt crisis[11]

The current international debt crisis had its origins in the oil price rises of 1973 and 1980. Petroleum exporting countries made huge profits and deposited large amounts of petrodollars in Western banks. These were lent in turn by Western governments, banks, and finance institutions like the International Monetary Fund (IMF) and World Bank to developing countries at low rates of interest, ostensibly for the purposes of modernisation and development.[12]

However, little of this money was spent on social and economic development. Much of it went on arms. The average per capita expenditure on arms in the developing world is $38 compared with $12 on health. Some of it was spent inappropriately on prestige projects such as nuclear power stations, and much of it was reinvested back into Western banks. One African Head of State allegedly had a personal fortune which exceeded his country's national debt.

However, although some money has been unwisely spent, developing countries cannot shoulder all the blame. They have struggled against a rise in international interest rates and a fall in world commodity prices (which fell by a third in the 1980s) as a result of recession in the West. This has meant that expenditure has increased at the same time as incomes have fallen. Average incomes in sub-Saharan Africa and Latin America fell by 10-20% during the 1980s while the price of basic foods trebled.[13] The result has been that between 1982 and 1987 the total foreign debt of developing countries almost doubled, from US $650bn to US $1,190bn.[14] Africa's debt alone rose from US $212bn in 1986 to US $300bn in 1997.[15]

Western institutions have offered debt reductions, such as the Highly Indebted Poor Countries Initiative, but on the whole rescheduling of debt payments has been undertaken only on the condition that developing countries adopt 'structural adjustment programmes'. The austerity measures demanded by the IMF in particular, have meant that resources are diverted from health and education to the production of exports in order to make repayments.[16] Taking Uganda as an example the government spends $2.50 per head of the population annually on health but $15 per head on debt servicing.[17] To compound the situation there has been a long-term decline in the price paid for commodities relative to that of other goods. Christian Aid cite a Bangladeshi example: 'a power-tiller 20 years ago cost us 1.5 tonnes of raw jute...a similar power-tiller today costs us nine tonnes'.[18] The fall in price of developing world exports relative to developed world exports means that much more needs to be produced in order to maintain the same buying power.

To compound the problem, over the same period, foreign aid to the developing world has fallen in real terms. The international community agreed that member countries of the OECD (Organisation for Economic Cooperation and Development) should devote at least 0.7% of their GNP to development aid. Despite this, aid has fallen to a trickle and the trend is downward. The UK gives a mere 0.27%.[19] This means that since the mid-eighties the developing world has paid more in interest and debt repayments than it has received in new loans or aid![20] In 1990 developing countries received £28.3bn in aid but had to pay back £34.5bn in interest on their debts.[21] This is the equivalent of every man, woman and child in the developing world paying the industrialised north £17.40 a year.

So in summary, debt affects health by dramatically reducing health spending, but more importantly through disproportionately compromising the education and standard of living of the poor.

Does the Bible have anything to say about the issues of interest and debt? Interestingly, quite a lot.

Old Testament teaching on debt

Under the Old Covenant the Israelites were forbidden to charge interest on money lent to vulnerable parties: namely fellow Jews (mishpaha), sojourners (ger) and immigrants (toshab). Interest could only be charged from foreigners (nokri) (Ex 22:25; Lv 25:35-37; Dt 23:19-20). Indeed it was the very practice of lending at interest to the poor which threatened the stability of Israel's post-exilic society and sparked Nehemiah's righteous indignation and subsequent reforms (Ne 5).

The principle of no-interest loans is upheld by the wisdom literature (Ps 15:5, Pr 28:8) and the prophets (Je 15:10; Ezk 22:12). In fact, Ezekiel lists lending at interest as one of the vices of the 'violent son' along with adultery, theft, bribery, murder and occult practices (Ezk 18:8,13,17).

Conversely, we read that to lend to those in need (at no interest) is a mark of righteousness and leads to being repaid by the Lord and having one's children blessed (Ps 37:26, 112:5).

Despite these measures, the Old Testament Law was realistic that some people would get into debt that couldn't be repaid and made a number of provisions for such cases. For example, the taking of security on debts was limited to measures that would not deprive a person of the basic necessities of life or jeopardise his livelihood (Ex 22:26,27; Dt 24:6,10-13,17). The Old Covenant also stipulated that every seven years any Jew who had to undertake 'voluntary slavery' in order to pay off outstanding debts (Lv 25:39-40) was to be set free (Dt 15:12-18). At the same time all creditors were to cancel the loans they had made to fellow Israelites (Dt 15:1). In addition laws concerning tithing (Dt 14:28-29) and gleaning (Lv 19:9-10) helped to meet the needs of the poor. The excessive accumulation of private property was frowned upon by the prophets (Is 5:8, Mi 2:2), and if a man became poor and was forced to sell his land it would be returned to his ownership every fiftieth year, the year of Jubilee (Lv 25:8-13, 28).

However, the Old Testament laws were not all one-sided. Borrowers had responsibilities too. They were to give refundable pledges as security on loans if requested (Dt 24:10-13), and had an obligation to repay debts and make restitution for losses (Ex 22:14, Ps 37:21) even if this involved selling property or working for the creditor (Lv 25:8-55).

Overall, these laws meant that there was adequate reward for hard work while ensuring that no-one got too rich or too poor.

New Testament teaching on debt

In general, Jesus upheld Old Testament moral principles (Mt 5:17-20; 23:2-3), especially those relating to economics. His followers were to go beyond the mere letter of Torah such that their lives epitomised the very principle of self-sacrificial love on which it was founded (Jn 13:34-35).

He said his followers should lend, even to enemies, expecting nothing back (Lk 6:35), habitually forgive debts (Mt 6:12, Lk 4:19) and give generously (Lk 6:38). The teaching of the apostles and indeed the practice of the early church underlined this general principle. Even the poor, but especially the rich, were to live within their means and give generously to those in need (Rom 13:7-8; 2 Cor 8:2-4; 9:6-8; 1 Tim 6:17-18). When current cash reserves were inadequate to meet needs property was to be sold (Lk 12:23; Acts 4:34).

These practices ensured that in the early church surpluses habitually met needs within and between communities (Acts 4:34-35; 2 Cor 8:13-15).

The parable of the talents (Mt 25:14-30; Lk 19:11-27) is about using our resources in a way that honours God but it has often been used by Christians as a justification for lending at interest. In reality it likens the practice of putting money in the bank to collect interest as 'reaping where one has not sown' in keeping with the Old Testament teaching already outlined.

In summary, New Testament teaching on economic ethics goes above and beyond the very radical principles of the Old Testament.

How has the church throughout the centuries interpreted these biblical teachings?

Church teaching on debt

The early 'church fathers', men such as Basil, Chrysostom, Clement, Tertullian, Ambrose, Jerome and Augustine accepted biblical economic principles without question.[22] They encouraged generosity and debt forgiveness and condemned the taking of interest.

The early Church Councils followed this precedent. According to Canon 20 of Elvira (300AD), unrepentant receivers of interest were to be ejected from the church. Canon 17 of Nicaea (325AD) proposed being 'struck from the register' for the same offence.[23]

Typical of the outspokenness of the church during the Medieval period was a decree from the third Lateran Council (1179) which barred 'manifest usurers' from communion and even Christian burial.[24] Interestingly, the distinction made by some modern authors[25] and even certain translators of the NIV Bible[26] between 'interest' (legitimate payment for a loan) and 'excessive interest' or 'usury' (illegitimate extortion) has no sound exegetical basis.[27]

Up until and including the time of the Heidelberg Catechism (1563) the taking of interest was regarded as equivalent to theft.[28] However, at the time of the Reformation, conservative and radical reformers were divided as to whether interest charges should be allowed under certain limited circumstances.[29] From this time on there was a gradual erosion of enthusiasm for biblical economic law. One might conjecture that the political support for the Reformation based mainly in the newly emerging capitalist countries (Holland, England and Germany) had a part to play in this. The result is that the issues of economic sin in general and the taking of interest in particular are seldom tackled from the pulpit today.

Nearly all Western Christians take a firm line on, for example, sexual sin or foul language. By contrast, most would never forgive debts, always lend money at interest and give away far less than a tenth of their income without a second thought.

Pointing the finger

Just as the AIDS epidemic could have been easily averted by following the simple biblical principle of 'one man, one woman, for life', so the international debt crisis and its consequences for health could have been avoided if the Western banks and countries had adhered to Old Testament teaching. However, finding a solution for the present debt crisis is a complicated issue.

It is easy to point the finger at others, but the real question is 'what about the church, Christian organisations and ourselves? Have we stood out as being different from the world on this key issue?' Apparently not.

As one well-publicised example (although there are many more), let us consider the Church of England. Its 1.16m members give on average about 2.5% of net income to the church. As a result the church makes up the shortfall by investing assets to earn interest. In 1990 this amounted to £140m or a third of its running costs.[30] If church members were to give a mere 5%, let alone tithe, the church's considerable assets of £2.36bn[31] would be freed from the necessity of collecting dividends, interest and rent. What possibilities for service would then be open?

What about our organisations? The recession earlier this decade has demonstrated the extent to which many Christian charities had previously relied on investment income. Now that inflation is so stringently controlled, interest rates are low and investment income is inadequate to meet needs. But why should it be necessary at all? If Christians gave at the level of the biblical minimum, there would be three times the amount of money presently available for churches and charities.[32]

And finally what of ourselves? Most Christians rarely think twice about lending or borrowing money at interest and demanding repayment in full. Bank deposits, savings accounts, credit cards, personal loans and mortgages are accepted as necessary features of modern life. Perhaps that is why we are so silent on the issue. As future doctors, all of us are going to be earning more money than we can spend, and if we haven't already, we will be faced very soon with the decision of how to use the surplus. Financial advisors frequently visit hospital messes eager to tell newly qualified doctors how to invest for maximum return and a secure future.

How will we respond?

First, we need to think through the issues fully and to decide to take a stand while still a student. Good habits formed now will last a lifetime. We need to be generous in our giving (Mk 4:24) and carefully think through how much we should give and to whom.[33] We also need to learn that our security should be in God rather than in possessions and money (Mt 6:19-34).

It is good to think through how we should invest any savings we might have inherited, earned or be going to earn when we qualify. The issues involved can be very complex but good literature on the subject from a Christian point of view is available.[34] There are many 'ethical' investment schemes. These avoid companies that support corrupt governments, promote warfare, or are involved in practices that damage health.

On a wider level we can get involved in the campaign to end developing world debt. Jubilee 2000 is a coalition of churches, aid agencies and charities that have taken the Old Testament idea of Jubilee as their model. They are seeking the cancellation of the unpayable debts of the world's poorest countries by the year 2000. You can get an information pack by writing to the address below.[35] It would be a great idea to get your CU/CMF group to raise awareness of the issues in your university/college, to write to MPs, or hold a meeting at which issues of poverty, debt and giving are discussed from a biblical point of view. It could even provide an opportunity to share the gospel-news of God's cancellation of our 'debts' through Jesus' death on the cross!


As we have seen, the international debt crisis has resulted at least in part from the failure of Western banks, governments and multi-lateral finance institutions to follow the straightforward biblical principles of no-interest loans to the poor, periodic debt forgiveness and reasonable, proportionate charitable giving. This is having profound adverse effects on health world-wide through the social and economic consequences of austerity measures imposed on developing countries by creditors. However, the Western Christian church, which should be leading by example, remains largely silent, having itself neglected these same principles. In Scripture we read that judgment begins with the house of God (1 Pet 4:17) and that righteousness exalts a nation (Pr 14:34). Perhaps then, it is time for us to repent, as individuals and as a church, and to put our house in order before we point the finger at others.

'Do not store up for yourselves treasures on earth, where moth and rust destroy, and where thieves break in and steal. But store up for yourselves treasures in heaven, where moth and rust do not destroy, and where thieves do not break in and steal. For where your treasure is, there your heart will be also.' (Mt 6:19-21)

  1. Bergstrom S, Mocumbi P. Health for all by the year 2000? BMJ 1996;313:316
  2. Logie DL, Benatar SR. Africa in the 21st century: can despair be turned to hope? BMJ 1997;315:1444-6
  3. Bergstrom S, Mocumbi P. Art cit
  4. WHO Report published in the World Health Statistics Quarterly 1989;42(4)
  5. Ibid:11
  6. Guerrero et al. Letter to BMJ 1998;316:1456
  7. Ibid
  8. Ibid
  9. Ibid
  10. Bergstrom S, Mocumbi P. Art cit
  11. Much of the following material is taken by permission from Saunders P. Death by Debt. JCMF 1993; July:3-7
  12. Christian Aid. Banking on the poor. London: Christian Aid, 1991
  13. Clark J, Allison C. Zambia - Debt and Poverty. Oxford: Oxfam, 1989
  14. Christian Aid. Op cit
  15. Smith T. Third World Debt. BMJ 1992;304:388
  16. Logie D. The Great Exterminator of Children. BMJ 1992;304:1423-6
  17. Oxfam. Poor country debt relief: false dawn or new hope for poverty reduction? Oxford: Oxfam, 1997
  18. Madden P. A Raw Deal: Trade and the World's Poor: London: Christian Aid, 1992:17
  19. Logie D. Art cit
  20. World Debt Tables. The World Bank. Washington DC,1990-1
  21. Gillen D. Decade of disaster. BMJ 1991;303:1017
  22. Mooney S. Usury: Destroyer of Nations. OH: Theopolis, 1988:34
  23. Jurgens W. The Faith of the Early Fathers. Collegeville: The Liturgical Press, 1970:254-5,286
  24. Cleary P. The Church and Usury. Hawthorn, 1972:26
  25. eg Unger M. Unger's Bible Dictionary. Chicago: Moody Press, 1979:1129
  26. see NIV translation of Ezk 18:8,13,17 with footnotes
  27. The issue is further discussed in Mills P. The Old Testament Ban on Interest. Jubilee Centre Working Paper
  28. Schaff P. Creeds of Christendom. Grand Rapids: Baker, 1977, 3:347
  29. Conservative reformers such as Luther, Calvin and Zwingli favoured interest under certain restricted conditions.
  30. Gledhill R. Church urges freer giving. Times 1990; 25 October
  31. Gledhill R, Hidalgo L. Church is warned of problems on pay bill. Times 1992; 17 June
  32. Brierly P. Act on the Facts. London: Marc Europe, 1992:100
  33. Pickering M. Nucleus, 1998; January:29
  34. For example from The Jubilee Centre, Jubilee House, 3 Hooper St, Cambridge, CB1 2NZ. Email:
  35. Jubilee 2000, PO Box 100, London, SE1 7RT. Email:
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