Chapter 5: Primary Health Care, Evangelism,
and Church Growth

I. PHC and Christianity

The dietary and sanitary laws of the Old Testament, given in the books of Leviticus and Deuteronomy, are excellent examples of primary health care teaching. In addition, the organization of PHC, with delegation of responsibility to the least trained health worker able to handle the health problem, is very similar to the legal system suggested by Jethro to Moses in Exodus 18.

It will come as no surprise then to discover that the basic concepts of PHC are consistent with our biblical heritage in a number of ways. First, by focusing on the health problems of the poor, the target population is the same group of people among whom Jesus had his ministry.

According to our Lord, the starting point is at the bottom of the socio-economic ladder, with the outcasts. The gospel is not confined to this level, but this, nevertheless, is the major area of its emphasis.. Our Lord teaches that it is the poor and the captives who are most receptive, and who embody the greatest potential. The rich and the wise are the minority by virtue of the needle's eye. Only God could think of starting at the bottom. Only he can do anything creative at this level. (cf. Matthew 9:13; Luke 5:27-32; Mark 2:13-17) (Charles H. Troutman 1973:106)

Second, PHC incorporates the sense of justice which promotes an equal access to health care service for all.

Third, PHC is good stewardship. It admits to limits in resources and the need to allocate intelligently those resources to address the basic needs of the greatest number. This is in line with the original creation mandate which is still obligatory on all men. (Genesis 1:27-30)

Fourth, PHC requires people to be responsible agents in their own environment, to make wise decisions about their own health and development, and to have a sense of self-worth and self-reliance. The concept of each person being responsible before God for his behavior is central to Christianity.

It can be argued that not only is PHC conceptually Christian, but that Christians are ideally suited to be effective health care workers. If one looks at the list of skills and character traits required to be an ideal PHC worker, few if any would qualify. How can any person be expected to understand another culture and language so well that those in that other culture will want to change their ideas about the nature and cause of illness, their health worldview, and at the same time to be able to withstand the attack of the occult and the cultic? "All the powers of hell will break over you as you try to step out in faith and try to teach others." (Jean Morehead 1985:13) Precisely because the task of initiating permanent change in another people's life and worldview is so humanly impossible, Christians, who rely on supernatural powers given by an omnipotent yet loving and personal God, should be the most effective agents of long-term change.

Christians know that the Prince of this world will not give up ground easily. There will be a struggle. "From resource depletion to political destabilization, we are wrestling with principalities and powers that are diametrically opposed to the initiatives of God in history." (Tom Sine 1981)

John Alexander states this point emphatically:

The forces against us are too much. We have no hope of winning. We need God to act. Any work among the poor must expect God to act or it is not deeply Christian. Work for development or justice which does not expect God's intervention is practical atheism even if it is done by Christians. (John Alexander 1980)

On the basis of these considerations, one might be justified in expecting Christians to be the best PHC and development workers. However, it must be conceded that there are devoted people who serve others solely out of a humanitarian spirit who are very dedicated and effective. We can learn much from them.

Christians have played major contributory roles in health and development in communities, however, not only as individuals but collectively.

The community nature of the church provides the opportunity for the demonstration and the outworking of trust and cooperation not normally found in human society. Thus the church is the ideal center for ministries of evangelism and community development. (Peter Batchelor 1981:130)

It is important that social and spiritual liberation occur together and complement each other. If only social liberation occurs, there merely emerges a new ruling class. Without spiritual liberation, the poor become materialists. This is what Maurice Sinclair terms "the barrenness in man-centered development." (Maurice Sinclair 1980:28)

II. PHC and the Social Gospel

In advocating Christian mission involvement with PHC to more effectively address the real needs of poor people in the Two-Thirds World, there is no shadow of the old social gospel. The social gospel believed in man's basic goodness and sought the etiology of his problems in the environment and adverse social conditions, e.g., poverty, hunger, war, disease, ignorance, etc. But the social gospel failed to see that the "basic problem is man himself, who needs to be forgiven and transformed." (Charles H. Troutman 1973:102)

Continuing this theme in an address to the Medical Missionary Association annual meeting, Dr. Patricia F. Wakeham of the Bible and Medical Missionary Fellowship International said:

For if we analyze the causes of ill-health we find that so much of it is due to man's intrinsic selfishness and sin. . If health for all is to become a reality, man needs the saving power of Christ to free him from himself. The Good News is that this power is available to all who will receive it. This is what gives meaningfulness to our Christian medical care. (Patricia F. Wakeham 1985)

Secular social scientists make similar observations about man's basic problem. ". . .man is invariably the agent of many of his own diseases, in that, his state of health could be determined more by what he does to himself than what germs do to him." (P. N. Otti 1982:11)

"Man cannot be changed from the outside in, as the liberals would have it. The pig will change the parlor, not the parlor the pig." (Norman Geisler 1982)

The transformation which is from the inside out is what the Bible calls being "born again." Only such a radical solution will free up an individual from culturally rooted beliefs and ideologies which inhibit change and restrain a person from being all that God wants him to be.

If the basic cause of human misery and disease is a consequence of the Fall, then the process of restoration must be based upon getting men and women right with God. However this is described, this process is evangelism, not the social gospel, and it is a fulfillment of the Great Commission.

While evangelism concentrates on allowing people to make individual decisions about their relationship with God, there is and always has been a community component as well. Dr. L. Nelson Bell, for many years a missionary in China, stated it this way:

We are apt to think too closely merely of the evangelistic effect of our medical work upon patients; it should be looked for rather in the community. The great spiritual value of our Lord's healing did not come to those actually healed, but to the healthy who beheld the Power and Spirit of what was done. Men who come to us for physical healing are not often seeking spiritual results in proportion to the effort expended.. It softens hearts, not so much the hearts of the physically ill as the hearts of the community's healthy, thinking men. They thus come to see the religion of Christ as something living, vital, essential to their own welfare. (L. N. Bell 1935:355)

Ill. PHC and Development

PHC can be an effective means of meeting both physical and spiritual needs of people, if done by Christians in conjunction with the local church. This is the type of wholistic healing ministry for which evangelical missions should be aiming. This is why medical missionary Ruth Dix wrote: "The most important part of a PHC program is its being an evangelistic arm of the local church." (Ruth Dix, Kenya, AIM:1985)

Change does not come easily in cultures dominated for centuries by witchcraft, superstition, ancestor worship, fear and fate. Breakthroughs in spiritual discernment come about through divine intervention via the person of the Holy Spirit. Freeing men from the bondage of both disease and sin was the task of Jesus (Matthew 11:4-6) and remains a priority of missions today.

Once freed by Christ's transforming power, men in every culture become new creatures. All kinds of possibilities open up. Ethnic, cultural, gender and racial differences do not remain the insurmountable hindrances to communication and fellowship that they tend to be for people outside of God's "Forever Family."

What is development? "Etymologically, development means 'unfolding,' the opposite of to 'envelope.' It is a God-given normal process allowing the growth and unfolding of human potentials in community." (John F. Robinson 1980)

Mission work is really development work, and for this challenge transformed minds are necessary.

People with a liberated spirit are the most essential development ingredient. This liberated spirit is the biggest advantage we have working through the church. Here we find a community of people who have been liberated from fear, superstition and counterproductive habits, fear of failure, fear of political oppression and fear of evil spirits. All of this has been removed through the liberating effect of Christ and His work on the cross. We find the people most receptive to change are those liberated people in the church. (Sam Birkey 1978:3)

Another missionary thinker has suggested that development be thought of as follows: "Development is the process by which persons and societies come to realize the full potential of human life in a context of social justice." (Edgar Stoesz 1975:3)

If development is thought of in this perspective, it becomes clear how evangelism and PHC are related to it. It is:

. . . in Christ that a man finds his own full development, and it is in Christ that a man finds the adequate motivation and the inner resources enabling him to contribute acceptably, creatively and effectively to the development of others. True evangelism does a work of development second to none. (Maurice Sinclair 1980:102)

Development, like conversion, is a personal and internal process. The former President of Tanzania, Dr. Julius K. Nyerere, has written: "People cannot be developed; they can only develop themselves. . .man is not developed if he is herded like an animal into a new venture." (Julius K. Nyerere 1967:2)

Thus, evangelism and PHC principles are interrelated components of Christian development. Both are necessary because man is a whole creature whose value does not rest completely on either body or soul, but on their unity.

IV. PHC and Church Growth

Three nagging questions about Christian health care ministries and church growth are:

1. Have mission hospitals been effective in evangelism?

2. Do health care ministries have to document spiritual growth in order to be valid?

3. Would adding a PHC program to existing mission health ministries be a more effective means of promoting church growth?

I believe that the answer to the first question is a qualified yes. Most mission hospitals have contributed to church growth, some more than others. There have been a few, however, which are located in particularly resistant areas, where spiritual results in terms of converts and churches are sparse. In some instances it has even appeared that institutional medical work actually hindered the growth of the church.

An example of a resistant area is China in the mid-19th century. "During one 12-year period the Medical Missionary Society of Canton treated more than 400,000 patients but managed to convert only a dozen of them to Christianity." (Theron Kue-Hing Young 1973:251)

Or, again, in Tanzania.

Patients demonstrated an amazing ability to accept the benefits of Western medicine while incorporating its practice and benefits into their original world and life view. Lack of success may have been due to an incomplete understanding of the culture and religion of the people, and the failure of medical missionaries to relate their medical treatments to the spiritual power of Christ. (Terence 0. Ranger 1981:261)

Even in areas where converts are made, few churches have been established. One missionary writes: "Few mission hospitals can point to local churches planted; why? Mainly because of inadequate follow-up of converts and inquirers, through lack of staff." (Raymond Windsor 1982)

There are some outstanding success stories, however, among mission hospitals in terms of churches planted. In Swaziland, where the Church of the Nazarene began general mission work in 1907, and educational and medical work in 1923, there has been tremendous church growth. Over 80 churches are in the north of the country, and 15 more recently established churches in the south. These southern churches were founded mostly by nurses trained at the mission's nursing school, or by teachers from the mission's teachers college who had been assigned by the government to work in the south. As a result of the medical, educational and evangelistic work, approximately 10% of the population of Swaziland will claim in surveys that the Church of the Nazarene is their church. (Paul D. Wardlaw 1986)

Dr. Link Nelson, a physician working with the Association of Baptists for World Evangelization at Bethel Hospital in Malaybalay, Philippines, saw the number of churches grow from 20 in 1951 to 120 in 1979. Since 1978, he has been involved in starting three small hospitals in rural areas of the Philippines, all three built at the initiative of church planting teams already working in the area. Each of these small hospitals is now staffed by two Christian Filipino physicians and is financially self-supporting.

In Indonesia, the medical witness of the Conservative Baptist Foreign Mission Society has been instrumental in church growth in a direct and an indirect way. While there have been converts at the 57-bed hospital, the major contribution of the healing ministry has been to give credibility to the entire ministry of the CBFMS in the province and the country as a whole. "Possibly this Muslim country would not have received and tolerated Christian missions without medical or other development ministries." (Wendell and Marge Geary 1986) They have seen the work grow from three small, struggling churches in 1962 to 80 established churches with membership of just over 3,000 adult baptized believers in 1985.

There is some question, however, as to whether local church growth adjacent to a mission hospital is due to the medical ministry or if it is due to the fact that the hospital is an institution which allows for the consistent influence of a concentrated group of missionaries. If the latter is true, then any stable institution with missionaries might see similar results.

One medical missionary in the Philippines reported to his mission the following observation: Our denomination has large numbers of churches in and around Davao, Mati, M'lang, and Marbel. In three of these four places, there is a mission institution: a college in M'lang, a seminary in Davao, and a hospital in Mati. My hypothesis is that church growth has been rapid in these areas not because of the institutions per se, but because they have ensured the presence of numbers of missionaries over a long period of time. This has fostered continuity. (J. Paul Seale 1984A)

Question 2: Do mission hospitals have to document spiritual growth in order to be valid?

Here the debate waxes hot, and arguments are lengthy on both sides. Those on the negative side argue for shaking the dust off our feet and moving on if the Gospel is not accepted. Cut our losses and be good stewards! Those on the other side note that just being there in a compassionate ministry constitutes at least a "presence evangelism," fulfilling the command of Christ to go into all the world. Whether results occur or not is not up to missions, but to the Lord of the harvest!

Here, as in other areas of Christian life and thought where committed Christians sincerely disagree, there must be sufficient grace to allow different responses by different groups. One side simply cannot be declared correct and the other in error.

Each mission hospital and each mission is unique. While no blanket rules apply, it is essential that mission leaders and medical missionaries periodically critically review their situation and experience. The challenge of being good stewards of the resources the Lord provides, and being faithful witnesses of his power, will always create the need to listen carefully to the leading of the Good Shepherd's voice.

Question 3: Would adding a PHC program to existing mission health ministries be a more effective means of promoting church growth?

Here I believe the answer can be a resounding yes. Peter Boelens of the Christian Reformed Church saw fifteen churches started in South Korea in five and one-half years when the mission moved out to become involved with PHC, including foster care of abandoned infants. (Peter Boelens 1983:27)

Now Dr. Boelens is the Executive Director of the Luke Society, a group of 300 Christian physicians and dentists in the Christian Reformed Church. The Luke Society has been instrumental in establishing PHC programs in a number of countries including the Philippines. The Filipino program is led and maintained entirely by Filipino health workers. Dr. Boelens writes:

PHC and preaching are the most effective form of evangelism we've seen in the Philippines. In the past six years, the Luke Society has seen twelve churches planted on the islands of Negros and Panay. These are indigenous, self-propagating, self-supporting, self-governing churches with trained Filipino pastors. (Peter Boelens 1986)

To date, the PHC program in the Philippines has trained 140 paramedics. Dr. Russel D. Atonson, the Director of the PHC program, writes:

. . . the most effective and valuable workers among our paramedics are the pastors, Bible workers, and church planters. They consider the paramedical work a part of their ministry, and as such the two functions are closely intertwined. To them, the medical work is a means to contact people, help them and eventually lead them to Christ. They are supported in their work by local churches and/or local mission organizations. (Russel D. Atonson 1986)

A seasoned church planting missionary with SIM International presented a paper at a mission meeting in September, 1981, entitled "Primary Health Care and How It Facilitates Church Planting." (Gerald 0. Swank 1981) In the paper, he noted that "PHC provides a better medical channel than we have had heretofore, by demonstrating at the village level the love of God for man. By meeting felt needs, the PHC team approach enhances the opportunity for spiritual impact upon the community."

This same paper presents a case in point from Galmi, Niger, West Africa. An SIM hospital has been in Niger for 30 years.

During this time hundreds who passed through the hospital professed faith in Jesus Christ. However, follow-up in the villages was generally impossible due to lack of staff, scattered villages and difficulty of travel. There is a church at the hospital but none planted in the villages. In 1979, a PHC program was started with a target population of 15,000 Muslims in fifteen villages. The villages opened up for the first time to an evangelist, working on the PHC team. The people remain open and interested. More has been accomplished in two years than in 30 preceding years. The possibility of churches in these fifteen villages is now very real. (Gerald 0. Swank 1981)

Others have remarked on the linkages between PHC and church planting ministries. Dr. Andrew Ng, Medical Coordinator for SIM Francophone Area, notes:

Because mental and spiritual health are intimately related with physical health, sooner or later a person's physical being will be affected by poor spiritual health. Hence, to care for their spiritual need while taking care of their physical ones is to take preventative measures. . .We need to recognise that missionaries are endowed with different gifts. . .and the average missionary doing a health ministry cannot also do church planting. I would suggest that we make sure that church planters are integrated into the PHC project team right from the start. The physical domain cannot be forever on the move without a simultaneous moving forward of the spiritual domain. There is no conflict in promoting both simultaneously. (Andrew K. C. Ng 1986)

V. Christian Development

Missionaries are obliged to fulfill both the Great Commission and the Great Commandment. Social concern, including health care ministries, and evangelism must function together as two wings of a bird.

As the ministry to the whole man takes place, true individual and community development can occur. The words of a Zairian pastor are appropriate. "Development is learning to give instead of receiving. As long as we keep asking for things, we are not developed. Only when we are able to do things ourselves so that we can help others are we really developed." (Pastor Pambi, Vanga, Zaire:1986)

Change through development requires liberated people. The church is composed of people who have been freed by the power of Christ to become new creatures. Christians in the local churches have a pivotal role to play in community development. But great care should be exercised in planning and implementing development projects, especially in areas where there is no church or a young, rapidly growing church. (Jim Yost 1984:360)

The main task of the Christian church is not mere social betterment or improvement in the standard of living of people. The task of the church is to demonstrate how to live the Christian life in the environment in which the individual Christian is placed. Development plans can proceed, but "without true spiritual integration of life based on the acceptance of Christ as Sovereign Lord, there can be no change." (Robert G. Cochrane 1940:16)

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