by Howard G. Searle, Samuel Rowen, Gustavo Parajon, J
Medical missions has understandably become the subject of careful reappraisal for many mission agencies.
Why are so many nurses and some doctors currently finding their ministry outside the mission hospital? What impact is this having on medical missions in particular and on the program of the church in general? In light of these and other equally discomfiting questions, medical missions has understandably become the subject of careful reappraisal for many mission agencies. Mission planners are currently grappling with issues such as: (1) the definition and purpose of medical missions; (2) the most effective use of resources and personnel; (3) the integration of program with economic, political and social realities.
Approaching the average mission hospital early in the morning, medical personnel mentally divide the number of patients waiting by the available hours in the day. They assign 3 to 5 minutes per patient, hoping this will provide adequate time for those really needing medical care. In some cases, nurses or paramedics may screen those waiting. Alternatively, the number of patients to be examined may’ be limited, resulting in the frustration of those not treated. In either arrangement, inevitable emergencies arise and demand the attention of nurses and doctors, prolonging the work day and trying the temper of both waiting patients and weary staff.
The typical medical mission institution is inadequately staffed and funded, and overburdened from the day it opens. While skyrocketing inflation rapidly prices voluntary agencies out of the international health field, burgeoning populations continue to beat a path to their doors.
Do we question the resultant phenomenon of "burn-out" among missionary nurses and physicians? Do we really wonder at the "bad-mouthing" of colleagues, an understandable indicator of the high level of frustration under such unremitting working circumstances? Are we surprised by the sense of guilt that so often follows the limited opportunity for sharing one’s self and faith? Are such conditions reflecting God’s love? Is there another approach?
The experience of some would indicate clearly that taking health care beyond the walls and confines of the mission hospital may provide part of the answer. This move may indeed help to lighten and undoubtedly make more selective the load of out-patients and in-patients at the average hospital by (1) utilizing a broader range of health personnel, (2) involving the villagers and encouraging a sense of responsibility for their own health care, (3) emphasizing health education and preventive health care, and (4) ensuring early local simple treatment of common illnesses, avoiding the costly and time consuming treatment of unnecessary complications.
The World Health Organization’s Alma Ata Declaration of September 1978, "Health for All by the Year 2000," has now been signed by all World Health Organization member countries. What contribution can Christian health care ministries, for the most part currently limited to a hospital based response to sickness and injury, offer toward the goal? Is there a more positive approach to health care that utilizes community based health education and promotion in conjunction with simple curative care, and which can focus on the basic common ills whose prevention can be taught to village level workers who, in turn, can teach their village peers?
In June 1981, MAP International convened the 9th International Convention on Missionary Medicine, under the theme "Medical Missions in the 80’s – A Quest for Priorities." Some cogent presentations were made on significant health development issues. Immediately following the ICMM, an ad hoc group of 40 mission leaders, each involved in various aspects of medical missions, met for two days to study these issues. A declaration entitled "Christian Health Care Ministries – New Directions and Opportunities" and a study guide were prepared by a steering committee and are now being circulated to mission leaders. (Available at no cost from MAP International Box 50, Wheaton, Ill. 60187.)
Rather than providing a definitive statement about the best direction for Christian health care, this article is an invitation to participate in addressing important questions about program direction and to consider the most effective strategies in providing health care in the context of Christ’s love for people in need.
To this end, five individuals have contributed their own perspectives to this symposium.
I. Definition: A Biblical View of Health
The need for a definition of health is intimately related to missiological issues. The various definitions of health-Western, Chinese, Indian, African, etc. -each has a definite cultural orientation.1 They embody a world-and-life view. To assume, for example, that a Western definition of health should control our approach to health is, at best, cultural imperialism. Yet, a much more subtle danger is the uncritical acceptance of non-Christian values in current health care methodologies.
The alternative of viewing the definition of health as simply culturally relative is also unsatisfactory. The task is not merely to accommodate or adapt to the world-and-life view of a given culture, but to participate in its transformation so that it more fully reflects the glory of the Creator. The task is to bring our understanding of health under the judgment of Scripture.
There are three central biblical themes that form a backdrop for our understanding of health-the nature of man, the nature of the people of God, and justice.
1. They way we view man affects the way we decide to deal with him. With the rise of modern science has come the view of man as a machine. The Western view of health is generally negative. If a person isn’t ill, then he is healthy. The task of the health agent is to "correct those faults in the body machine." In contrast to this, Tony Atkins describes an African’s view of health: "Most Africans think that health is symptomatic of a correct relationship between people and their environment … Concepts of health in the African framework of culture are far more social than biological. . . "2 No culture is so devoid of God’s restraining grace that it fails to reflect some dimension of Christian value. However, every culture has been affected by the Fall. The Christian vision must allow the light of God’s grace to shine through and at the same time judge those dimensions that have been twisted and distorted by sin. The biblical view of man as made in the image of God provides one lens through which we can focus our understanding of health.
2. A second biblical theme is the nature of the people of God in the world. The church is a community of people. Wholeness in life is communal. Salvation is both individual and corporate in nature. When an individual repents and receives the blessings of the gospel, he is incorporated into the Body of Christ. Man as a social being is seen not only in creation, but also in God’s redemptive intentions. Our understanding of health must embrace this social or communal dimension. This communal dimension characterizes his pilgrimage. The pilgrimage is also a call to mission. The mission is to do the work of God according to his will. This is why acts of mercy-the giving of cups of cold water in Christ’s name-can be at the same time acts of worship. The ministry of worship, edification and witness are specific in focus. They are, however, inextricably related to acts of mercy. There are no dichotomies in God’s economy.
3. The third theme of justice is pervasive in the Scripture. The concepts of righteousness and justice are essentially interchangeable. Thus, the admonition is to "seek first the Kingdom of God and its justice 11 (Matthew 6:33). The goal is the Kingdom of God and justice is the sinews of that kingdom. Sinews are the cords that weave their way through the body to provide strength and shape. So acts of justice provide concreteness of form and are evidence of the power of the Kingdom of God. justice is a complex issue, but it does have some minimal implications. Justice demands that all men be treated and related to in a way befitting their dignity as image bearers of God. Health can be appropriately viewed as "a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity."
The Christian vision of life calls us to responsible action to God. We are responsible to God for how we act in respect to God, in respect to ourselves and to others, and how we act in respect to the created natural order. Medical resources are one of the means to help people fulfill this responsibility. The glory of the Creator is more perfectly revealed when health is part of human experience. Therefore, the extension of medical resources cannot be only a precondition to something else, e.g., conversion, discipleship, etc. The extension of love and mercy reflect the character of God even when the recipient refuses to recognize his responsibilities to God.
II. The New Agenda: Community Based Health Care
Generally speaking, in our traditional medical programs, the people we serve have been considered to be passive recipients of the services that the health professional has to offer. We seem to have forgotten that health is a most important area in an individual’s life and that with the gifts he or she has received from God, there is much that that person can do to preserve and to improve health. A superficial look is all that is needed to determine that health problems can only be solved when a community participates in and is given a central role in the problemsolving process. Health problems cannot be solved by health professionals alone, using the hospital as a base.
We as evangelical Christians can understand the concept of community participation more completely. We believe and emphasize the priesthood of all believers. We have the biblical conviction that every member of God’s community has a gift that must be exercised in conjunction with the gifts of the other members to carry out the ministries entrusted to this community. It is not only the spiritual leaders of the community who should carry out their ministry in this way.
Provadenic, a Christian medical program in Nicaragua, found that when the community actively participated in the health actions, the mortality rate of children under 5 years of age dropped dramatically from more than 20 percent to less than 2 percent. The community had accomplished in a relatively short period of time what the health professionals could not have done alone.
To involve the community in its own health care, health professionals should consider that they are now part of a team in which the members of a community are integral parts. In addition, the role of education-of teaching health concepts and enabling the other members of the team to carry out health promoting activities-is a new and vital dimension of their roles.
Health care is a human activity that is part of a larger whole: the development of people in addition to their Godgiven resources. Health activities have an impact on other areas of life, just as activities in other spheres also affect health.
In a community where it has been decided to grow cash crops such as coffee or tobacco instead of vegetables and sources of protein, the health and nutrition of infants may deteriorate rapidly, despite the most effective curative services offered. However, if a community is motivated to work for a source of clean water, gastroenteritis and other intestinal infections may become less frequent and this, in turn, can improve the health of the community. Socioeconomic development in a community may provide more income for people to improve sanitation and nutrition and hence their health, although specific "health" actions have not been taken.
In this context, we must also be aware of how social injustice and exploitation destroy people and thwart their development. When a local church is being led by the Spirit to serve the community by sharing the good news and by ministering in other areas, it has the potential to work effectively in the development of the total person and his spiritual, physical and emotional health.
The stewardship of the resources God has entrusted to us is an issue that needs to be addressed. In light of the tragic needs of many of the world’s people, we are responsible to best use these resources and personnel in the various geographical areas to which we have been called to minister.
In our study and analysis we must consider community based health care as an important new frontier for our Christian health care ministries. Christian missionaries have been in the forefront of community based health care, and their models have stimulated the World Health Organization, as well as governments, to evaluate these concepts and recommend them as viable opportunities to reach the great number of people in need of health care.
III. Institutional Responses to Primary Health Care
What, then, are some of the implications for Christian institutions in accepting the responsibility to initiate the process of primary health care? The majority of medical missions are still located in rural areas of developing countries where the health problems of vast underserved populations are most acute. It is in this setting of staggering need that the challenge is posed to missions to be the cutting edge of effective health care. The Christian response may well determine the health of the majority of the world’s people. The pivotal point in a commitment to the "new tasks" of our mission institutions will be the adoption of a new mind set.
Paramount to accepting the privilege of initiating primary health care will be a proper understanding and response to the question Jesus asked the lawyer in the biblical passage of Luke 10. It will be the mind set that moves away from asking, "Who is my neighbor?" to one which seeks to know, "Unto whom am I neighbor?" The latter question places the responsibility for initiating caring on the man who asks the question. Translated to Christian health care ministries, this question probes the willingness of mission agencies to accept the coresponsibility for the health of a community in a new way-to accept responsibility beyond merely those who are able to reach their medical institution’s doors.
Very few clinics or hospitals can supply accurate data as to what conditions exist in a five-, ten-, or twenty-five mile radius, or from what diseases the surrounding population is sick or dying. Fewer still are addressing these health needs in preventive terms. We have not addressed our potential for making a lasting impact on our neighbor’s health. The lawyer’s question in Luke 10 is ever with us, and the answer may bring us to a new commitment.
The second attitude change deals with methodology and rests upon the first. If the Christian health care institution first establishes a commitment to reach out to its neighbors with an effective health care ministry, the question follows: How best can one be a neighbor? This second mind set embodies the belief that the ultimate responsibility for health rests with the community itself. It is the attitude that values and supports the ability of village and community people to learn to be part of the health care team. It is not threatened by the knowledge that there are many forms of education critical to the healing process in addition to curative technology. It acknowledges the fact that we are learners and healers together.
Martin Reyes, a young administrator working with David Werner in a primary health care program in Ajoya, Mexico, perceptively defines the role of Christian health care institutions as "supporters, not supervisors" in the process of promoting primary health care and community development. Drs. Raj and Mabelle Arole of the Comprehensive Rural Health Project in Jamkhed, India, have stated the same point.
The role in primary health care for mission institutions is, then, as supporters of a process that gives validity to the healing abilities of those who are within the communities we serve. All other institutional implications take their genesis from these two conceptual positions; all other needs will prove secondary.
IV. Medicine and the Health Worker
Becoming supporters of a process that promotes community based health care calls for a radical departure from the Western medical model of health care in which the "allknowing" M.D. is in charge and all others are his helpers. At the root of this revolution is the shifting of responsibility for health from medical professional workers to community based workers and, ultimately, to the people themselves. Hafdan Mahler, Secretary General of the World Health Organization, has said that if present medical knowledge could be made available to all the world’s people, it would be the greatest advance in the history of medicine. Any success at making health care widely available will depend on this simple but vital health knowledge reaching people where they live.
The most important members of the new health team are the people themselves. Looking at the health problems on a world scale, this is not unreasonable. The world’s three most devastating health problems are malaria, diarrheal dehydration, and malnutrition. All can be prevented in the home if the inhabitants are provided the simple knowledge needed.4
The best person to provide this knowledge is a person chosen from the community and by the community to be trained as a teacher. Chosen out of respect, he/she will best understand the community and be understood by them. As part of the community, Christian primary health care workers can have a long term opportunity to earn the right to share-at the most appropriate times and places-the gospel of God’s healing love through Christ.
The health worker will be trained to understand and teach prevention, as well as to diagnose and treat common illnesses and minor injuries by simple means. Thus, while costly open heart surgery may briefly extend the life of a few, the simple efforts of a community health worker can save the lives of hundreds. While elaborately equipped intensive care units may save the lives of a few desperately ill with malaria, the community based health worker can prevent malaria in countless more. The worker chosen by the community will share his/her knowledge of primary health care with as many as possible to the benefit of all.
In such a scheme, the doctors and nurses must of necessity be helpers and supporters, assisting in the preparation of teachers to instruct community health workers to communicate health care concepts to the people. (The skills of doctors and nurses will, of course, continue to be needed for the more complicated cases beyond the capabilities of the health worker and community.) Home board recruitment will thus need to include appropriately trained individuals willing to work in roles significantly different from the traditional Western medical model. However, in this way, smaller numbers from the sending agencies will have the capability to accomplish more extensive and more effective health care.
This is a difficult and radical concept in the Western world, where more and more health resources are being expended for decreasing returns. Yet, powerful examples in effective community based primary health care systems are increasing around the world. Christian ministries have historically led the way in health care. God is clearly calling us to blaze a new trail toward bringing his total healing to those in need in a shrinking world.
V. Implications for Mission Executives
For missions currently involved in hospital work, the emphasis on community based health care can afford opportunities to move into wider ministries among people at greater distances from the hospital ministry itself. For missions not presently involved in medical ministries, community based health care offers an effective and viable means by which to evidence love and compassion. Such ministries are integral to the larger network of major mission health care systems or similar government systems. The potential for effective community based health care ministry or expanded health programs is considerable, and missions will want to explore possible opportunities presented by the growing interest in primary health care.
However, there is growing discussion about a concept that views health as something that is to be maintained by the people of a community themselves. Health care knowledge and basic remedies are made available to them through the teaching of appropriately trained community leaders. Most individual health needs can be handled at the community level and through local people trained in very basic health care concepts that substantially improve the opportunities for building and maintaining health. Obviously, hospitals and institutional care are still essential for appropriately addressing more serious conditions.
This situation impacting on health is similar to the issues addressed by mission institutions in the case of theological education by extension. Some missions wanted to (and some did) close seminaries and fully endorse TEE. Others resisted TEE as "’inferior" education. In the end, most reached the consensus that the institution was critically needed, while TEE was also crucial to expand the base of theological knowledge to more people.
There is potential for conflict if hospital managers and medical staff take the attitude that primary health care is "inferior" medicine and resist efforts to implement primary health care programmatically. Because of their desire for excellence, the medical profession and government officials may discourage community based health care activity. Even if such health care is endorsed by the government, trained doctors, nurses and local medical professionals who serve the mission may have difficulty in accepting the concept. They may be reluctant to work with people whom they consider "incompetent" or "improperly trained" to do "medical" work.
On the other hand, some advocates of community based health care may talk of closing the hospitals and placing all of a mission’s resources in primary health care to reach the "90 percent" who do not have access to the hospitals. The mission administrator will need to create an atmosphere conducive to open communication in which these points of view can be discussed and where a consensus with regard to program direction can emerge.
Commitment to community based health care may involve many types of programs, such as training community health workers and/or training Christian workers in basic health techniques. The local church could very easily become heavily involved in ministering to the local village as an outreach ministry. There are enormous ramifications that should be carefully scrutinized for opportunities in church planting and ministry.
In view of the above, mission boards need to re-examine their policies related to health care ministries. Those not having policies need carefully to consider formulating policies relating to all aspects of medical and health care work. Missionaries currently in their places of ministry can take a fresh look at the needs and opportunities that surround them and begin to develop programs that could effectively bring together their outreach concerns and their health care concerns.
Training institutions, both domestic and overseas, will need to examine the possibilities of incorporating some basic training in their curriculum that addresses community based health care and the role of Christian workers in creating the kind of community spirit that is necessary to develop such health care programs. Missions also need to consider the issue of the management of community-based health care programs. Will such programs be best managed by doctors and medical people, or by appropriately trained managers of development activities?
We have examined briefly the basic issues of purpose, programmatic direction, attitude, implementation, accountability and stewardship in the field of health care ministries. These raise several questions: Does our current involvement in Christian healthcare comprise the most responsible biblical expression of Christ’s love and compassion? What exactly is involved in health education and health care promotion at the community level? What training and preparation are required to prepare adequately those who will be involved in health care programs?
Should our health care program include a community based component? What percentage of resource commitment should be extended to community based health care, and what percentage to hospital based care?
What are the implications with regard to recruitment and staff training for the teams of health professionals needed for these challenging new frontiers of involvement?
What are the implications to missions in considering this broadened mandate for health care ministry? As we examine our mission policies, are they current, relevant, directive? Do these policies enable us to guide wisely potential missionaries to appropriate training for emerging responsibilities? Do these policies facilitate our responsible recruitment of new candidates and/or preparation of current missionaries for changing roles and relationships?
Can we open ourselves, our motivations, and our work to honest and objective evaluation? Great needs exist. In addressing these needs, roles, tasks and relationships may need to be redefined. New categories of personnel may need to be developed. New administrative and financial resources need to be explored and tapped.
We must reassess the health care needs confronting us, commit ourselves to our neighbors worldwide, and effectively enable the ongoing involvement of members of communities in their own health care through the prudent direction of program and resource commitment. With God’s enabling we can respond effectively and compassionately to the challenge.
1. John M. Janzen, "The Development of Health" (Development Monograph Series 8). Akron, PA: Mennonite Central Committee.
2. Tony Atkins, "What is Health?" (Keynote address at International Conference on Missionary Medicine, June 3-16, 1978). Wheaton, IL: MAP International, p. 5.
3. ibid., p. 4.
4. David Hilton, (Health Teaching for West Africa, Stories, Drama, and Song). MAP International, 1980.
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