Re-imaging Medical Missions: Results of the PRISM Survey

by Mark Strand with John Mellinger, Tina Slusher, Alice Chen, and Allen Pelletier

Comprehensive survey of potential medical missionaries reveals significant challenges in the days to come.

The medical missions1 enterprise has been in existence since the work of the Catholic orders in the fourteenth century. Protestant missionaries were late to the game, beginning with Dr. John Thomas in India in 1773 (Campbell 2000, 425-426). Growing steadily in numbers through the nineteenth century, the number of missionary doctors on the field reached an initial peak of 1,125 in 1925, not counting the number of nurses and ancillary medical workers (Price and March 1959, 2). This peak has likely been surpassed in the last twenty years, if missionaries from all countries are considered, but no data exists to prove it.

Medical missionaries contributed to the establishment of modern medicine in many countries of the world, and patient contact was historically and continues to be a first and substantive point of contact for local people to encounter the gospel of Jesus Christ (Loewenberg 2009).

In regions where medical work has been well utilized as part of the mission methodology, it has been effective in building the Church of Jesus Christ. For example, the work of medical missions has contributed to the establishment of a church in Nepal of over a half million Christians today. In India, it has been reported that eighty percent of the Christians relate their conversion to a mission hospital experience. If a circle were inscribed with a 50-mile radius around each of the original 272 mission hospitals in China, one would find that these are the areas of revival today (Adolph 2009, 1). Many Muslim countries with some degree of resistance to Christianity, such as the United Arab Emirates or Bahrain, have supported mission hospitals as a valued member of society.

Although medical missionary work has created some of the most enduring missionary legends, it has continually struggled to find its place in the missionary enterprise (Grundmann 2005). The earliest medical missionaries to China in the 1830s, led by Peter Parker, struggled with how to apply their vocation in medicine in a way that supported the work of the mission, but they were still sorely misunderstood by the mission organizations. Here is how their dilemma was described:

The medical missionaries, while caught in the middle, were indispensable to both (medicine and ministry). It was only through the wonders of medical treatment that the message of the Church’s teachings could reach the people, and on the other hand it was only through the respectability of religious affiliation that the medical missionaries could bring credit to the medical profession. (Young 1973, 272)

In the last ten to twenty years, broader mission trends have revisited the ministry value of medical missions. For example, focusing the mission work primarily on the establishment of church-planting movements has called for a reevaluation of whether or how medical work accomplishes that purpose. “Evangelism only” emphases have put pressure on medical missionaries to justify their soul-winning results. The complexity of medical work has also led some organizations to prioritize community health evangelism over clinical medicine.

To some degree or other, all of these trends resemble the tension felt in medical missions during the liberal-fundamentalist controversy of the 1920s, when evangelical mission organizations were accused of going liberal if they put too much effort into education, medical work, orphan care, or other mercy ministries. But a closer look shows that the “evangelism only” focus of faith missions was more the rhetoric of home councils and conservative home constituencies than the real experiences on the field of the missionaries themselves. Bill Svelmoe writes,

Despite the taint given to social work in the struggles between liberals and fundamentalists at home, conservative evangelical missionaries on the field hardly skipped a beat, continuing, until the Depression slowed them somewhat, to construct schools, hospitals, orphanages, coffee-curing plants, and so on. (Svelmoe 2003, 201)

It makes one wonder whether there might be a similar discrepancy today.

Each generation frequently considers itself to be at the end of an era (Anderson 1954). The current generation of medical missionaries likewise find themselves in a time of transition. The PRISM Survey set out to answer three pressing questions currently swirling in the mission world:

• What is the real experience of seasoned medical missionaries and how is it changing in the current setting?
• Are mission organizations prepared to provide the training and strategic leadership necessary for medical personnel to thrive in their mission settings, and what is the unique role and vision for medical work in the mission endeavor?
• With improving health care systems all around the world, what niche are medical missionaries meant to fill, and what are the unique opportunities awaiting the new generation of medical missionaries?

Methods
In 2010, the Continuing Medical and Dental Education (CMDE) commission of the Christian Medical and Dental Association (CMDA) commissioned the PRISM Survey: Patterns and Responses in Intercultural Service in Medicine.

Potential medical missionaries were invited to take a 34-question online survey. Paper surveys were also distributed at conferences attended by medical missionaries. Inclusion criteria included licensed medical missionaries (not only MDs), with more than two years of work in their host country, proficient in English, and associated with a Christian organization. A total of 393 valid responses were included in the analysis.

Results
Finding #1: These are seasoned medical missionaries who successfully adapt in the face of disappointments. Respondents to the PRISM Survey represent seasoned medical missionaries at a point of stability in their careers. The average age is 48 years (men, 51, and women, 45) and the average time of service in medical missions is eleven years; 49.9% and 50% are male and female, respectively.

Respondents come from 18 different countries and serve in 67 countries in all regions of the world; 67.7% are physicians, 17% nurses, and 15.3% are in other health-related areas.

Exactly 41.2% intend to serve until retirement and the rest intend to serve into their mid-50s. There is no evidence that Gen-Xers (those born between 1965 and 1980) are less committed to long-term service than Baby Boomers, as reported length of commitment for both is statistically equivalent.

Their Work Setting
Fifty percent work in a mission hospital or private clinic and 13% work in government clinics. Seventy-one percent work in Christian settings, but compared to early medical mission work, they now increasingly work in diverse settings. Eleven percent are working in secular settings not supportive of their Christian faith.

Medical Missionary Roles
On average, these missionaries are spending 61.2% of their time on medical work (36.1% on patient care and 25% on other medical areas; see figure 1). This leaves 39.9% of their time spent on a combination of administration, organizational leadership, hosting visitors, and church-related responsibilities.

Figure 1: How time is spent 

 

  Respondents are generally satisfied with their role (only 16.4% report being somewhat or not satisfied), even though 33.8% found their role not to be what they expected (see table 1). The bimodal results shown in table 1 suggest two different, but strongly-held opinions. While a majority of medical missionaries are satisfied overall, many are not.

 

Table 1: Satisfaction with work and ministry balance and role consistency 

As medical professionals, these missionaries are accustomed to functioning in work settings with clear goals and quality control. The diversity of methods in their mission organizations and the complexity of the settings in which they work make it difficult to create this level of focus and quality. One respondent wrote, “We often feel that we went to a foreign field planning to practice medicine, but the situation required us to take on many other responsibilities.” New workers coming out will increasingly expect clear job descriptions, with flexibility. Some groups have found that new workers to the field need a staged process of mentoring and coaching into their role so that by year three or four they are competent in and confident of their role.  

One-third of respondents report having experienced significant depression, and one half significant anxiety. Medical missionaries are survivors. With strong faith in God and adaptive methods, they press on (Editorial 2009). But it is important that perceptive member care workers and organizational leaders assume that they are experiencing this level of stress, and provide needed assistance in coping with it.

Finding #2: Sending organizations are not supporting medical missionaries in a clear way, creating some level of uncertainty among the missionaries. When asked how their sending organization would respond if they told them they were leaving medical work to focus on other areas of ministry, 38% say their organizations would prefer that they leave medical work, and only 19% say their organization would not want them to do that. What group of employees anywhere could thrive if nearly 40% of the staff felt their boss preferred they changed jobs?

When asked if they perceive their organization to be moving away from hospital and clinical work, 38% agree and the same percent disagree. Here is how one respondent explained it: “My organization claims to be recruiting doctors, but fails to reveal areas where direct patient care is needed; rather, it advertises for evangelistic/church-planting projects, with medicine being a secondary or minor role.”

Despite the fact that many respondents perceive their organizations to prefer they leave the medical work, 83.6% of the missionaries themselves consider medicine as essential or important to their purpose in being a missionary. Also, among their biggest challenges are lack of staff (32.5%), lack of money and equipment (16.1%), lack of a good strategy (8.1%), and lack of a plan for the sustainability of the work (7.3%), all of which call for more support and direction from their sending organizations. One respondent explained his concern like this:

It seems to me that missions governing bodies without significant numbers of medical personal do not seem to understand the needs of medical missionaries or the different paradigms we work under in evangelization, i.e., we should not be treated or utilized under the same paradigms as non-medical ministries such as church planting.

Finding #3: Global health is changing rapidly, creating both threats and opportunities for medical missions. In the past, it was assumed that medical missionaries were going to fill gaps or provide essential medical services that did not exist in the countries in which they served. When asked to compare the quality of health care in the area where they serve to five or more years ago, 58.9%, 27.7%, and 13.4% report it to be improved, the same, and worse, respectively. National health systems in many regions of the world are improving, in some cases dramatically, so the concept that medical missionaries can or should provide the backbone of health services is no longer universally true.² Local hostility on the part of host governments is not perceived to be extensive, with 64.8% of respondents reporting the local government to be very favorable or favorable to their presence there and only 1.3% considering the local government to be unfavorable. This favorable working relationship is extremely important to their ability to have a positive impact, and requires constant attention from leaders in medical missions.

Opportunities in Medical Missions
Respondents consider teaching and training local medical professionals and mentoring Christians in medicine to be the best opportunity and best way to have a positive impact on the health of the people locally (see table 2). However, it is also known that credibility to train and mentor another implies that one is already successfully working in that profession, so meaningful clinical work is necessary if one intends to mentor national colleagues.

Table 2: Prioritizing ways to impact the health of the
local people and opportunities in medical missions

Historically, medical missionaries were keen to serve the most underserved people and this need will continue to exist for medical missionaries indefinitely. However, a new era creates new opportunities, to which we will now turn our attention.

Conclusions
Conclusion #1: The Medical Missionaries. The cross-cultural medical workers surveyed here are committed to long-term service and bring a unique set of skills to the cause. Their role on the field is often not what they expected, and many experience significant levels of anxiety and depression, yet they remain faithful in service and find satisfaction in what they do. Clinical medicine remains their primary focus of work, which is as it should be in order to serve as excellent medical trainers and mentors of both national Christian medical workers and new expatriate medical missionaries. The level of multitasking required of them is high, which may impede their ability to be truly effective and productive in a few areas. They need stronger support and focused leadership from their organizations.

Conclusion #2: The Mission Organizations. Medical missionaries consider themselves a key piece in the mission enterprise, and their medical work as a part of the overall calling to preach the gospel. But they often feel the need to force their medical work to fit their mission organizations’ vision or strategy, rather than the medical work being a part of that vision. In the biblical model of the body, each part does what it does best, in partnership for the gospel. The role healthcare workers play in healing is an essential part of the process of caring for people in whole ways, and supports the work of preaching and teaching.

At a time when many medical professionals are going to creative access countries, a mission strategy and vision is called for that includes the professional role they will fill (Long 2000). It requires a theological and a missiological understanding of vocation and one’s role in society that allows for expansion of the space within which effective ministry can be done, and better tools for doing it (Ramstad 2011).

Some respondents reflect concerns that their mission organizations are not prepared to guide medical missionaries or utilize them well. Such organizations should stop recruiting medical personnel. Other organizations that intend to stay in the medical arena need to put more resources toward making the medical work they do successful. Some key pieces include: incorporating the medical work into the overall mission strategy; putting more people into successful or potentially successful medical work locations rather than allowing each medical person to strike out on his or her own; and even closing down unproductive or unhealthy medical missions projects. An intentional process of mentoring new medical missionaries is also called for.³

Conclusion #3: The Changing Global Health World. Economic progress, political confidence, and improving health care systems in host countries are calling medical missionaries to thoughtfully consider their role in these settings. This role needs to be legitimate and appropriate to both the health needs of the people and the health care system already existing. It also needs to fill a strategic ministry purpose, both in terms of the holistic health care being provided and in the way it supports the local Body of Christ.

Although the host countries tend to look favorably upon these missionaries, it is getting harder to get permission to do medical work in these countries, and frankly, these countries increasingly perceive themselves as able to tend to their own health care needs. So it is important that medical missionaries increasingly view the world as it views itself if they hope to maintain and even grow their opportunities for the gospel.

Pressing global issues such as HIV/AIDS, mental health, human migration, disaster relief, and human trafficking present opportunities for critical contributions to vulnerable populations. At the same time, new focuses such as medical research, residency training, and systematic management of chronic diseases present opportunities to make novel contributions in the development of strong national health care systems. Medical work is a close-knit global society, using highly uniform standards of diagnosis and care so partnership and collegiality are not difficult to create in medicine. This is just a small glimpse into the opportunities available in the current global health climate.

Mission hospitals are still a primary work setting for medical missionaries, and the legacy and witness they offer should be preserved, albeit in creative ways. Relative lack of interest in pursuing financially sustainable models of mission suggests that medical missionaries are focusing primarily on patient care. This should remind mission organizations to put greater priority on staffing their facilities with capable administrators and financial officers, particularly nationals who will remain there indefinitely.

The purpose of medical missions needs to be re-imagined and clarified, as medical missionaries are increasingly called upon to add unique value, engage in more training of national co-workers, and model ingenious and evidence-based strategies of care, not just for individuals but for whole populations and health care delivery systems. The people served through medical work and the colleagues with whom these respondents work are in need of the hope that only the gospel of Jesus Christ brings, and medical work remains a key means to make it happen.

Endnotes
1. “Medical missions” here refers to the enterprise of long-term cross-cultural missionary service through medical work under the auspices of a Christian missionary organization.

2. This does not take into consideration the fact that these “improving” health care systems are not likely Christian in nature, and do not care for the spiritual needs of patients.

3. The Center for Medical Missions of the Christian Medical and Dental Association offers pre-field training for medical missionaries, and is currently working to prepare a set of benchmarks which will identify the knowledge and skills that a medical missionary needs to accrue over time to be a competent and effective medical missionary for the long term.

References
Adolph, Harold. 2009. “Current Trends in Medical Missions.” CMDA.

Anderson, Harold G. 1954. “The Changing Pattern of Medical Missions.” Occasional Bulletin of the Evangelical Missiological Society 5(11): 1-13.

Campbell, Evvy. 2000. “Medical Mission Work.” Evangelical Dictionary of World Missions. Ed. A. Scott Moreau, 425-426. Grand Rapids, Mich.: Baker Academic.

Editorial. 2009. “What Is Health? The Ability to Adapt.” The Lancet 373(9666): 781.

Grundmann, Christopher H. 2005. Sent to Heal! Emergence and Development of Medical Missions. Lanham, Md.: University Press of America.

Loewenberg, Samuel. 2009. “Medical Missionaries Deliver Faith and Health Care in Africa.” The Lancet 373(9666): 795-796.

Long, W. Meredith. 2000. Health, Healing and God’s Kingdom: New Pathways to Christian Health Ministry in Africa. Waynesboro, Ga.: Regnum Books.

Price, Frank W. and Arthur W. 1959. “Protestant Medical Missions Today.” Occasional Bulletin of the Evangelical Missiological Society 10(03): 1-10.

Ramstad, Mans. 2011. “And What Do You Do Here? A Theology of Vocation and Its Missiological Implications.” Occasional Bulletin of the Evangelical Missiological Society 47(3): 1-8.

Svelmoe, Bill. 2003. “Evangelism Only? Theory versus Practice in the Early Faith Missions.” Missiology: An International Review 31(2): 195-206.

Young, Theron Kue-hing. 1973. “A Conflict of Professions: The Medical Missionary in China, 1835-1890.” Bulletin of the History of Medicine 47(3): 250-272.

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Mark Strand, PhD, is associate professor in the Masters in Public Health program at North Dakota State University. Prior to that, he served in many leadership capacities  with Evergreen, devoting his time to developing sustainable primary health care systems with the Chinese government. Mark co-wrote this piece with John Mellinger, MD, Tina Slusher, MD, Alice Chen, MD, and Allen Pelletier, MD. The reader is invited to engage in discussion with the primary author at MarkStrand3@gmail.com. Copies of the full report can be obtained by contacting him.

EMQ, Vol. 49, No. 4, pp. 430-439. Copyright  © 2013 Billy Graham Center.  All rights reserved. Not to be reproduced or copied in any form without written permission from EMIS.