This is a monograph about medical missions--what has been, what is, and what might be. Its purpose is to bring to the surface some concerns and to make a few projections about the direction of international health ministries within the context of Christian missions.

It is urgent that people seriously interested in international health ministries take the time to evaluate the current situation and clearly delineate our objectives. This seems to be an important juncture in the history of medical missions as we shift course from Phase 2 to Phase 3.

Phase 1 of medical missions could be called the doing phase. Pioneer medical missionaries of many different ecclesiastical and national backgrounds moved into nearly every country on earth in response to God's call. The difficulties they encountered and the hardships they overcame have been the witness of dedicated men and women. Some names in this group have become well known: David Livingstone, Albert Schweitzer, John Scudder, Paul Carlson.

Medical missionaries in the first phase took some medical equipment and skills, but primarily they brought hope, compassion and love for the people who suffered. Wherever this first wave of missionary healers went, they met people with obvious physical needs. In an attempt to address these needs, they established clinics and hospitals, and gave long hours and faithful years of service. They accomplished much during this doing phase.

It was not long, however, before medical missionaries realized that they simply could not personally provide all the medical care needed by the people they wanted to serve. It became obvious that training nationals at every level of the health care delivery system was necessary. This second phase of medical missionary endeavor could be termed the teaching phase.

In Phase 2, schools were founded to train doctors, dentists, nurses, laboratory technicians, X-ray technicians, physician assistants, dispensers, and nurses aids. Again, some medical missionaries in this group became well known: Peter Parker, Helen Roseveare, Edith Brown, Ida Scudder. Most did not achieve fame, but labored in clinics and hospitals not only doing quality medical care, but teaching it, too.

Today, the doing and the teaching continue. But we are confronted with changing conditions around the globe which call for a shift to a third phase in medical missions: the enabling phase.

Enabling differs from the previous teaching phase in four important aspects: (1) instead of a teacher-student relationship, the association between missionary and national is one of colleagues working together with mutual trust and respect; (2) the school, institution, or project is owned by nationals, rather than by the mission agency; (3) the goal is community development as opposed to purely individual development; and (4) instead of continual dependence of the Two-Thirds World on the industrialized nations, the direction is toward increased self-reliance, self-support, and sustainable indigenous growth and development.

The concept of enabling comes from experiences in development work and lessons from Primary Health Care projects. "Enabling is growth in the ability and willingness to exercise responsibility and is the essence of human development." (Donald Miller 1980:3)

The three phases of medical missions can be summarized using a familiar analogy. Giving a man a fish is doing. Showing him how to fish is teaching. Working with him to devise, build and manage a fish pond is enabling.

But before going into a further description of what I see in this phase for medical missions, we should look at some factors which make necessary the shift from Phase 2 to Phase 3. What issues are forcing us to reevaluate the way we have been doing medical missions?

1. The rapidly escalating costs of maintaining hospitals and schools in many parts of the Two-Thirds World.

2. The obligation to be good stewards of the limited resources placed at our disposal.

3. The inherent difficulties of any institutional work in areas of political instability.

4. The inherent difficulties of any Christian institutional work in view of the forces of secularization over a period of time.

5. Increasing control by many governments over the medical and educational institutions within their boundaries.

6. The openly antagonistic stance of many governments in the Two-Thirds World against any Christian mission work.

7. Increased anti-Christian militancy by many other religious groups, especially Islam.

8. National pride and the coming of age of many churches in the Two-Thirds World requiring treatment as equals.

9. Emphasis by the World Health Organization and its member states in Primary Health Care, community medicine, and public health.

10. The high turnover rate of medical missionary personnel (e.g., 8% annually among Southern Baptist missionary doctors--twice the resignation rate of the missionary force as a whole)(Ruth Fowler 1979:5), resulting in acute and chronic shortages of staff for existing mission hospitals.

11. Increased realization that "helping" people by doing for them is not always helping, but sometimes creates dependency, with negative long-term effect.

12. Problems which develop when mission institutions (hospitals and schools) operate separately from the indigenous church.

13. Despite heavy investments in effort, expense, and personnel over the years, some hospitals have yielded a paucity of results in terms of spiritual impact on the community. They thus fall short of one of the key goals of missions, that of making disciples and establishing fellowships of local believers.

14. The lack of impact on mortality and morbidity figures in catchment populations around a curative institution which is not involved in preventive and promotive Primary Health Care programs.

In the face of these realities, it is imperative that we evaluate where we have been, where we are now, and where we could be going. It is my desire that this monograph contribute to this examination process.

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