Medical Missionaries and the Role of Evidence

Slate's Brian Palmer is right: missionary medicine in Africa is largely unregulated, unstudied, and understaffed. I have seen with my own eyes—and performed with my own hands—clinical decisions that would rightly be considered malpractice in a developed setting because they required that procedures or medications used reserved for specialists be attempted in order to save a life (ask me sometime about the time I did hand surgery.)

What's more, I did so in Jesus' name, praying with and for patients whilst frequently consulting a chaplain to do some heavy-duty proselytization. Doing good for the sake of others doesn't require that one believe in Jesus; there are plenty of organizations and individuals who are providing medical care without any spiritual strings attached. But neither does believing in Jesus necessarily inhibit people from doing good, as Palmer seems to suspect.

This, however, is not the end of the story, though it's about all that Palmer bothers to talk about. The story of missionary medicine is more complicated— and expansive—than he realizes. One might think that a writer ostensibly dedicated to reason and scientific study might want to investigate the evidence that does exist—sparse as it may be—on the role of faith-based organizations and Christian missionaries within the medical systems of developing countries. Unfortunately, Palmer is content to fire off a few statistics about this bizarre tribe of missionaries and their backwards religious customs, then revel in horror at their unquantified habits of practice.

I have personally sat in meetings and seminars dedicated solely to exploring the ethical issues raised by practicing medicine in limited resources, using Biblical principles to sort out how to best care for patients in a way that is sustainable and merciful. I have listened to countless Christian medical professionals discuss the lengths that they go to in order to invest particularly in professional development for indigenous health practitioners. I have even been party to forums in secular professional meetings where the benefits and risks of an explicitly religious approach to medicine were openly debated. What's more, these aren't just my personal vignettes—they are an essential part of the numerous institutions that Christian missionaries train and serve in.

I certainly appreciate the historical nods that Palmer gives in his piece, acknowledging that criticism of missionary doctors goes back a long way. What he doesn't mention, however, is the fact that the modern enterprises of community health and international development were not only founded on the precepts of missionary medicine, they continue to be shaped by the work of missionaries. Much of the evidence regarding community-based primary health care strategies comes from Christian projects. The Alma Ata Declaration—a WHO document that lays out the foundational principles for evidence-based primary care health systems—was based strongly on the work of Christian missionaries who helped to convene multiple conferences in the 1960’s and 70’s on international health. As Carl Taylor, who helped write the Declaration, stated:

“Coming out of the conference, the entire global health community, developed and developing, was energized to ramp up health care around the world. The tenets of serving the poor, service to the community as a whole, disease prevention, and the pivotal role of women in health, developed following [Christian medical conferences] and refined by Christian Medical Commission, were firmly built into the evolving framework of Primary Health Care.” from The Christian Community’s Contribution to the Evolution of Community-Based Primary Health Care (PDF)

Beyond the crucial role that Christian missionaries played in helping shift the WHO’s conception of health from the previously dominant compartmentalized, top-down model of care delivery to a more generous understanding of health as a function of human flourishing that must be secured as part of a social justice agenda, there are numerous initiatives within missionary organizations today to carry on this legacy. For example, both the ongoing Global Missions Health Conference and the recently launched Christian Journal of Global Health are dedicated to the exact sort of research, analysis, and quality improvement that Palmer thinks are missing from modern missionary medicine-- which makes one wonder how hard he (or his editors) actually bothered to look into this subject. Most of the residencies dedicated to training indigenous physicians in Sub-Saharan Africa--whether surgeons or family doctors--are linked to one missionary organization or another. The “current emphasis of international health delivery” of education and training that he mentions? The Christian Medical and Dental Association even has a whole enterprise dedicated to it. A study to quantify who is working where and what they are doing that he hasn’t seen? It’s been out for 4 years! All of this is still bare-bones, but it’s disingenuous to suggest that medical missions is “a mystery,” as Palmer does.

Research and quality improvement are indeed lacking in Sub-Saharan Africa (although Palmer's mention of PubMed is laughable because you can use PubMed to find all sorts of papers written by missionaries, they just don't write "Christian Missions" in every title.) This is largely due to funding; most African countries have yet to devote the state funds necessary for ensuring basic healthcare provisions for their people, much less an ample funding source for research akin to the vast resources that NIH, charitable foundations, and pharmaceutical companies pour into investigation in the First World (and let's not forget that in America we have to have big public campaigns to get our highly educated professionals to actually follow the evidence that has been amassed because said professionals are so bad at following it). Many missionaries—already working long hours with limited resources—still find the time and money to collect clinical data, report it to whatever entity is willing to crunch the numbers, and use the results to shape their practice.

Beyond these concerns—which Palmer freely admits he might relinquish if secular physicians were carrying out the work—lies the question of faith. His willingness to admit that his discomfort about this issue won’t motivate him into an ideological crusade against health professionals who proselytize is certainly commendable. For a non-religious person steeped in a non-religious environment, it certainly seems apropos to be skeptical of missionaries who are open about their faith and wag a finger at those who would dare to use their position as a medical provider to share their beliefs with others. However, such an outlook is downright ignorant of non-Western conceptions of health and disease, which are far more open to spiritual causes of disease and more frank discussions of faith as it relates to health. In a world where cell phones and reverence for one's ancestors are equally valuable and many people inquire of a witch doctor before seeking medical attention at a hospital, it is not at all unusual or inappropriate to practitioners to discuss their own religion and how it might offer a better perspective on the suffering and fear that their patients are facing. I don't know if Palmer's piece was vetted by any Africans, but it doesn't seem to reflect any understanding of the holistic worldview that I have encountered among non-Western health professionals.

We do need to address the disquieting motivations that medical missionaries sometimes have for their work. Again, the white and wealthy cultural milieu finds animating spiritual convictions frightening for legitimate reasons and has ample historical basis for such fear (although the legacy of colonial missionaries is far more positive than most give credit for.) However, the dedication with which missionaries apply themselves to their work and the places that they choose to invest their labors are inseparable from the theological distinctives of evangelical Christianity. Just as the American Civil Rights Movement or the British anti-slavery movement cannot be understood without a deep appreciation for the religious teachings that shaped them, so missionary medicine is inseparable from the doctrines discerned from the Bible. Jesus' ministry of preaching and healing are inseparable—the Gospels are full of incidents where He challenges, exhorts, encourages, or rebukes one who has been healed or a crowd around Him as a part of the healing. At the very heart of Christian doctrine is the understanding that as Christ's suffering delivered us unto life, so our suffering as believers can produce similar fruit in others. Kent Brantly, Olivet Buck, and Jerry Umanos stand as excellent examples of such Passion-motivated compassion. Dr. Brantly survived his suffering for others, but Drs. Buck and Umanos did not—these theological convictions are what make Christian missionary medicine uniquely effective and continue to drive the disproportionate (but still insufficient) number of religiously based medical providers.

The deficiencies that Palmer notes in his piece are real, and mission work is desperately in need of the sort of resources we apply to Western medicine. However, both the spiritual aspects of Christian mission work and the rigor already applied to such medical endeavors are indispensable to the story of healthcare in Africa—even if if Palmer can’t be bothered to discuss them when he bemoans the lack of data plaguing health care abroad. Rather than casting aspersions and “standing aside,” those who love evidence-based practice ought to celebrate what has been done through missionaries, apply what they have to teach us, and follow them to places where just and equitable health systems are still being built.