Chapter 6: Trends in Health Care Ministries

This monograph has considered only one trend in medical missions, that of Primary Health Care. What other changes have been occurring in the past 20 to 30 years? The following are probably the most significant:

1. Tentmaking
2. Short term
3. Team approach
4. Continuing education
5. Board certification for physicians
6. Public health training
7. Family practice specialty
8. Personnel changes
9. Nationalism

Each of these merits notice as part of the missions context for the future of medical.

1. Tentmaking

"Tentmaking" alludes to the fact that the Apostle Paul, the great 1st century missionary of the church, supported himself through making tents while engaged in evangelistic ministry. (Acts 18:3) The beginning of the modern missionary movement also centered around a famous tentmaking missionary, William Carey.

As a cobbler in England, Carey's testimony had been: "My business is to witness for Christ. I make shoes just to pay my expenses." (J. Christy Wilson, Jr. 1979:31)

It was Carey's book published in 1792, An Enquiry Into the Obligations of Christians to Use Means for the Conversion of the Heathen, which helped catalyze the massive missionary activity of the 19th century. About tentmaking specifically, he wrote: "We have ever held it to be an essential principle in the conduct of missions, that whenever it is practicable, missionaries should support themselves in whole or in part through their own exertions." (Kenneth Grubb 1931:11)

Since World War II, the tentmaking concept has been revived and expatriate Christians in many countries are maintaining a God-honoring life-style and witness while utilizing their professional or technical skills in the workday world.

Medical tentmakers are of two types: (1) those who are members of an organized mission but whose support is partially or fully obtained from work done on the field, and (2) those who are completely independent and self-supporting. While no hard numbers are available, it is my estimate that the majority of medical tentmakers are in the second group. They are committed Christians who exercise their ministry through working with host governments, international organizations, humanitarian agencies, or in the private marketplace. They may be employed by government medical schools, U.S.A.l.D., Peace Corps, W.H.O., U.N.E.S.C.O., World Bank, etc. A recent issue of the Journal of the American Medical Association listed fifteen pages of names and addresses of organizations with openings for American physicians overseas. (252: 1985 (December 1 4):3101-3115)

Also included in this second group are Christian physicians who have decided for the sake of the Gospel to move their families and their practices to a foreign setting. From Hong Kong to Nairobi, such physicians maintain a cross-cultural witness for Christ through their private practice of medicine with no organic connection to any mission board.

This approach has numerous advantages. Tentmakers do not scare people off by being known as a missionary. They do not drain from mission/church funds. They have access into countries which are "closed." They often have more money for their family's needs. They can be effective witnesses within the medical profession in their adopted nation. They are often looked upon as helping with national development. They are free to respond to human needs which may not be part of a mission's program. (Howard Mattsson-Boze and Herbert Kane 1979:70) The major disadvantage to this approach is the possible lack of prayer support for their ministry. It would be best if each tentmaker developed an effective prayer team in the home country.

A good example of a tentmaking missionary employed by a host government is Dr. David Brabon. His parents were missionaries with OMS International in Colombia where he lived until age 16. After graduating from the University of Louisville School of Medicine, and while taking a surgical residency, he began applying for a license to practice medicine in Colombia. This turned out to be a seven-year bureaucratic nightmare, but the end result of his persistence was a license granted him in late 1983.

In January, 1984, he moved to Bogota, Colombia, and was employed as the Director of Clinics for the Simon Bolivar Regional Hospital. He also works in the Division of Plastic Surgery and with the largest burn unit in Colombia. In his contacts with patients, colleagues, and medical students, he is free to share his faith in Jesus Christ. He is excited about those to whom he has witnessed who have become believers.

For one month each year, he returns to the USA for a "furlough." During this month he does locum tenens work for vacationing Christian physicians. In this way he can supplement the monthly take-home pay he receives in Colombia ($320). (David Brabon 1986)

The first group of medical tentmakers--those who are members of a mission but earn part or all of their support on the field--are in the minority. Several mission boards are setting up provisions for this category of tentmaker, and I believe this will be an important option in the future.

SIM International has had this category of tentmaker for several decades. In Nigeria, many missionaries taught religious knowledge in the public schools and were paid for their teaching by the government. Rather than use these funds for support, however, the mission collected this money into an education account. From this account the mission was able to fund the seminary education of many proven Nigerian church leaders. This has helped immensely to strengthen the Evangelical Churches of West Africa (ECWA).

While in Liberia with SIM from 1980-1985, I was a medical tentmaker working as a pediatrician at the John F. Kennedy Medical Center and at the Medical College, University of Liberia. This was a marvelous opportunity to witness for Christ in a 600-bed, 90-doctor medical center, and among the African medical students who took their clinical rotations at the JFK Medical Center.

The Christian Reformed Church's Board of Foreign Missions has developed a category for tentmaking missionaries that is called the "Associate Missionary Program." Dedicated Christian professionals are recruited to fill positions in private and/or government enterprises in the Two-Thirds World. Two farm managers were sent out in early 1986, with openings in mid-1986 for medical personnel (doctors, nurses, lecturers), engineers (mechanical, electrical), additional farm managers, development specialists (manufacturing), computer systems analysts, and math and science teachers. (Gordon Buys 1986)

In Nigeria, the Navigators already have a physician working as a tentmaking missionary employed by a Nigerian private physician.

While some missions have not yet initiated a tentmaker category for missionaries, there is at least one mission which works only with tentmakers. This is Tentmakers International (formerly Overseas Counseling Service) whose Executive Director is Mr. Richard Staub. Tentmakers International (TI) matches jobs available overseas (16,000 openings as of June, 1986) with Christians interested in witnessing through "secular" occupations in foreign lands. During 1985,117 people were placed overseas through TI, with 70% getting jobs in restricted access countries. (Richard E. Matthews 1986)

There are some disadvantages to being a tentmaking missionary, and to complete the picture these must be enumerated. Again, from Wilson's book, these are:
1. The employer may try to limit one's witness.
2. No time is given to learn the local language.
3. Short terms of service.
4. Secular job may take most of one's time.
5. May be accused of being deceptive (missionary in disguise).
6. May be accused of having a double motive.
7. Lack of prayer support from home country.
8. May be housed in special area away from the local people.
9. Witness for Christ may backfire on the employer/company.
10. Lack of orientation that is usually given to missionaries.
11. Work involvement may leave no time for verbal witness.
12. Lack of spiritual accountability.
13. Lack of Christian fellowship in some places.
(J. Christy Wilson 1979:68)

Despite the reality of some of these disadvantages, it is my own opinion that the role of the tentmaking medical missionary will greatly increase in the future. If this could be accomplished within the context of organized evangelical missions, this might be ideal. The dream of having Christian health care professionals working with host governments, international organizations, and private enterprise, able to be salt and light in these places, is already becoming an exciting reality.

2. Short term

In the past, when one was called to become a missionary, it constituted a career-long commitment. Today, however, a significant share of missionary work is carried on by people who are short term workers. By short term, I mean a period of service for four years or less.

In medical missions, this involvement in short term mission can begin while still in medical school. Most medical schools in the industrialized world allow senior medical students to take electives in the Two-Thirds World for credit if the program is properly arranged and supervised. To help fund medical students seeking such exposure to missions, DeWitt Wallace, founder of Reader's Digest, established an endowment in 1971. The program, known as the Readers Digest International Fellowship (RDIF), is administered by MAP International (see Address Appendix).

J. Raymond Knighton, the founder of MAP, recently reported to the Christian Medical Society (CMS) on the success of the RDIF program. He noted that during 1985, the 1,000th medical student was sent to a mission hospital. He was pleased to report that about 10% of medical students who have gone out under the program have subsequently made a career commitment to medical missions. The popularity of the program is evidenced by the 4:1 applicant to recipient ratio. (J. Raymond Knighton 1986)

Graduate physicians in residency and those in practice can also participate in short term medical missionary projects. CMS has several Medical Group Mission (MGM) projects each year to Mexico, Honduras, and Haiti. The Canadian chapter of CMS had 212 participants in MGM projects during 1985. (Robert Clark 1986)

To enable USA physicians to work for two to six months in mission hospitals in the Two-Thirds World as volunteers, two surgeons, the Furman brothers, in Boone, North Carolina, established the World Medical Mission, Inc. (WMM), in 1978. So far this organization, directed by Franklin Graham, has sent out over 60 physicians. In July, 1986, WMM had 19 physicians serving in eight different nations of the world. Evangelical missions who find themselves temporarily short of medical/surgical staff can use WMM as a resource for qualified, committed short term help.

Aside from the organizations mentioned above which specifically are geared for short term medical missions, nearly every mission board or international Christian agency has opportunities for health care professionals to serve in a short term capacity.

A creative approach to short term medical missions is being tried in several locations by Christian physicians who are in group practice in the USA. In increasing numbers, these doctors voluntarily reduce their incomes in order to make it possible for one or more members of their group to be involved in short term missions on a recurring basis.

In Berrien Center, Michigan, 25 physicians in a private group practice (The Southwestern Medical Clinic) have set up a system of sponsorship so that each member of the group can be involved in medical missions, either in short term visits of two to three months, or as full-time missionaries who practice there on furloughs. During the year 1985, for example, three members made short term trips, while six were serving as career missionaries. Furloughing missionary physicians joined the others to help maintain the practice at home. (Robert S. Schindler 1986)

Dr. David Miller and four associates in a family practice group in Denver also cover for each other in order to do short term medical mission projects. With a twinkle in his eye, he noted that there are "risks" involved in this arrangement, however. One of the physicians from the Denver group found so much fulfillment in his short term experience in Central America that he has quit the group in order to join a mission in Ecuador. Two others became so interested in the problems of the poor that they began working part-time in an inner-city clinic in Denver. (David Miller 1986)

An orthopedic surgeon from Wheaton, Illinois, took his wife and their nine children to Kenya for an entire year of voluntary mission service. In the Epilogue to the book in which he records this experience, Dr. Paul Jorden lists seven things to know about short term missions:

1. Go where you are needed.
2. Go where you are wanted.
3. Be prepared to pay your own way completely!
4. Be aware that the full-time missionary is taking extra time taking care of you.
5. Be patient and expect to feel very inefficient.
6. Have a spiritual outreach to nationals.
7. Your contribution will be based on what you are, rather than on what you do! (Paul J. Jorden with James R. Adair 1985:317)

Short term medical missions is a growing trend due to increased travel opportunities and the ability to practice the technical aspects of medicine on short term arrangements in many situations in the world. Missions benefit in having additional manpower at minimal cost, and by making Christians more knowledgeable about the prayer and financial needs on the field when the short termer returns home. Although one cannot maintain a ministry relying only on short term volunteer helpers, missions would do well to encourage and recruit Christian health professionals, including pharmacists, dentists, nurses, therapists, and physicians, for this type of ministry.

3. Team approach

The basic concept of this trend is that coordinated teamwork, not solo performances. workers need to function together as members personal and professional relationships. modern medicine involves Therefore, Christian health of one team, with excellent The team approach recognizes that health is a much broader area than that of medicine alone, and that health workers of all stripes are valuable. An often neglected, but very important, member of the health team is the patient himself.

The glue that holds the team together is a common love of God and a commitment to serve people. The objective of the mission health team is to establish ongoing, indigenous, self-propagating, comprehensive community-based health in association with ongoing, indigenous, self-propagating local churches.

The team approach requires that every missionary be a part of the health/development effort. Even those not trained as health professionals can be effective promoters of health in the Two-Thirds World through role modeling and the teaching of basic health/hygiene concepts.

Professionals trained to understand people in other cultures, and those skilled at non-formal adult education, are invaluable members of the new mission health team. Particularly, people with backgrounds in cultural anthropology and adult education can serve as the sense organs for the mission body as it interacts with people. Anthropologists are experts at receiving information from others, while educators are experienced in the most effective methods of passing on such information to others.

The maintenance of good health is largely a matter of good health behavior, and the key to this is education. Although the word "doctor" means "teacher," most doctors today lack the essential skills to effectively teach good health behavior to the people of the Two-Thirds World, in contrast to these newer members of the health care team.

It is to be hoped that from Urbana conferences to Intercristo the call will go out concerning the urgent need for adult educators, anthropologists, agriculturalists, nutritionists, and those with administrative, planning and development skills to be joining the mission health care teams.

4. Continuing education

All members of the health/development team will need to plan continuing education throughout their professional career in order to perform adequately. The obligation to keep up is perhaps most obvious on the part of physicians involved in curative medicine. Yet, if it is difficult to keep up with the rapidly advancing pace of medical information in the USA, it is impossible to do so in most nations in the Two-Thirds World. How can anyone stay up-to-date with more than 7,000 articles published weekly in the biological sciences?

For physicians and nurses, there are ample tapes, cassettes, magazines and conferences to help keep abreast of developments in the medical field. Mission boards have generally encouraged their health care workers to participate in these programs as much as possible.

One new way missions have found to help their missionary physicians is sending them to Continuing Medical Education (CME) conferences arranged and conducted by the Christian Medical Society (CMS) of the USA. Since the early 1970's, the CMS has had a CME Commission which coordinates annual conferences, held alternately in Africa and Malaysia, for the purpose of upgrading the knowledge and skill of missionary physicians. The faculty of these conferences has consisted of over 70 different Christian doctors who teach in medical schools or practice in the USA.

From the first CME conference in Liberia in 1974, the attendance has steadily increased. Over 140 medical missionaries, many of whom also brought their families, attended the CME held in Nairobi, Kenya, in February, 1986. (Charles Kelley 1986)

The chairman of the CME Commission is Dr. David Stewart, a psychiatrist and former missionary in central Africa. The annual CME conferences are co-sponsored by the University of Louisville School of Medicine and the CMS. During the two weeks of each conference, participants can gain up to 60 hours of CME credit. Often this allows a missionary physician to maintain his USA medical license. The 1987 CME conference was scheduled to be held in Malaysia (January 12-22), with the next in Limuru, Kenya (February 15-25, 1988).

All missionaries, not only physicians, need continuing education. A missionary is not a finished product concept, but a continuous participation concept." (Kosuke Koyama 1974:129)

5. Board certification

In the past, missions have had such pressing medical needs that some physician candidates were recruited directly following internship. Now, many nations have their own medical education programs and an organized health system. Therefore, the requirements for the physician who desires to serve in missions are more rigorous, and specialization with board certification almost the norm. Obtaining board certification takes additional time after residency training. Despite the time delay in getting to the mission field, there are some reasons why this may be good. First, practicing for a minimum of one to two years in one's home country is looked upon as a credit by national colleagues and review committees both at home and abroad. Second, many young physicians will need this additional time to pay off educational debts that have accumulated. Third, during this time the candidate can take Bible/Theology courses to become better equipped to grapple with the spiritual struggles on the field. Several Bible schools and seminaries have graduate programs which are ideal for this purpose.

6. Public health training

In response to the need for public health and health education in the Two-Thirds World, rather than only curative medicine, many present and future candidates for Christian health care ministries are taking formal training in public health or preventive medicine. A masters degree in public health (MPH) is currently available at 22 universities in the USA. A number of these have specific interests and connections with health projects in other nations.

In the past, some medical missionaries and those interested in international health have obtained MPH degrees after a few terms on the field, often while on furlough or a leave of absence. Today, many candidates are getting this training prior to their first term. Because the medical education system of the USA has become so track specific, some insightful medical students who are planning a career in missionary medicine are taking a year off from medical school between their third and fourth years to earn their MPH degree. As a result, they do not have to interrupt their internship or residency training. Others are taking a combined MD/MPH program at their medical college.

The MPH degree is probably the best avenue to prepare a health care worker for community health or PHC. Such a degree is virtually a necessity if one wants to be considered for a position in international health agencies like W.H.O., U.S.A.I.D., or U.N.E.S.C.O. Many of the innovators in missionary medicine today are those who have MPH degrees.

7. Family practice specialty

Another trend in medical missions is the growth of one of medicine's newest specialties, family practice. From a lowly start in the late 1960's, it has become the most popular specialty of the 20 available, with 10% of all residencies being in family practice. (Journal of the American Medical Association, 254;1985(September 27):1587)

Family practice allows the physician to have basic training in the areas of pediatrics, obstetrics and gynecology, surgery, and internal medicine. Family practice as a specialty is excellent training for the person who wants to be involved in the broadening scope of health care ministries. The thinking of two recent medical school graduates is typical. 'We chose the family practice residency program at Cook County Hospital in Chicago because we believe it will give us the best all-round training for missionary medicine." (Steve Hawthorne and Daryl LaRussa 1985)

Paul D. Wardlaw, former medical director of the ten-doctor mission hospital in Swaziland, said: "Those trained in family practice who then get an MPH would be the most valuable missionary candidates." (Paul D. Wardlaw 1986)

Unfortunately, because family practice is such a new specialty, it is not recognized in some countries, such as Nigeria or India where one cannot currently teach this specialty in a medical school. But the training itself is most appropriate for the majority of the demands in a mission hospital. (A similar problem exists with the newest medical specialty, emergency medicine.)

8. Personnel changes

With various social changes taking place today, including early retirements and mid-career job shifts, there are more opportunities for middle-aged Christians in mission work. These people are often eager to embark on a second career and to do the Lord's work full-time. Some of these candidates have already raised their families.

In addition to an expanded age limit for candidates, there are at least two other factors which may lead to an increase in the number of health professionals applying to mission organizations. First, the USA has overexpanded its physician pool in the past 25 years. The number of physicians for each 100,000 people has grown by 51% since 1965. (Milt Freudenheim 1986:1)

Second, the increased cost of malpractice insurance and threats of litigation are causing physicians to reconsider medical practice in the USA. "In 1985 alone, 18% of all obstetricians will either retire or switch to another specialty as a result of the malpractice problem. Malpractice coverage for this group of doctors currently runs as high as $72,000 per year." (Time, 1985 (September 16): 56)

In the face of these forces operating in the USA, mission boards would be well-advised to be increasingly selective in regard to physician candidates. Only those with proper motivation and background will be helpful on the mission health care team.

It should be underscored here again that another major change in missions health personnel will be the increased use of other professionals besides doctors and nurses. Health educators, cultural anthropologists, field administrators, nutritionists, and specialists in non-formal adult education should be playing greater roles on the mission team of the future.

9. Nationalism

Most nations in the Two-Thirds World are still newly independent, with more than half of these less than 40 years old. While the temper for independence ran high in the 1950's and 1960's, the spirit of nationalism has not decreased significantly in the succeeding two decades. Nationalism is often a front for other forces at work, whether religious, ethnic, economic, or cultural. The end result is that increased sensitivity by missions and their personnel to national feelings is essential.

The level of sophistication of nationalistic feelings varies with geography. In Latin America a missionary from the USA may not be held liable for every action or position of the United States government, while in the Middle East he often is thus judged.

Partly as a result of the pressure from nations of the Two-Thirds World, the USA has closed the door on post-graduate medical educational opportunities for most non-USA citizens. This is likely to slow the "brain drain," but it creates difficulty for the mission or the national church wishing to arrange advanced training for young Christian health professionals. How can the process of indigenization take place in health care programs unless the national health professional can be trained to the level of the missionary health professional?

There is a definite need for post-graduate training for young national Christian physicians. Christian physicians in the industrialized world and mission leadership need to work out creative solutions to this impasse. This might require designing a program specifically for Two-Thirds World nationals at a Christian health institution in the USA, or of developing an educational program somewhere in the Two-Thirds World. The Christian Medical Society of the USA, or the International Congress of Christian Physicians, may be of assistance in addressing this problem.

Conclusion

Significant changes have been and are taking place in health care ministries. When they happen slowly, they tend to be overlooked. This chapter has attempted to focus on nine of these trends which currently impact in this area.

We must never forget that, despite the trends which are occurring, the basics stay the same. In seeking to fulfill the Great Commission and the Great Commandment, everything depends upon the "spiritual commitment of the personnel involved." (Terry C. Hulbert 1982:36)

For example, to be truly helpful to malnourished mothers and children, missions need nutritionists who

understand that people do not live by bread alone. The right food is essential, but also essential is a humanizing process in which the hungry find wholeness, dignity and freedom. This is the only kind of development which fits the Christian ethic of ministry to each person as a unique child of God. (Doris Janzen Longacre 1977:36)

[NEXT]

[OTHER PUBLICATIONS] [CONTENTS]