Global health: A new paradigm for medical mission?

Abstract

This article explores the practice of Christian mission in the developing field of global health care. First, the definition and context of global health is discussed. Second, the history of medical missions is traced, from their origins in biblical healing, through traditional medical missions in the 19th century, to today’s global health-care paradigm. Third, the situation of Christian medical mission today is described – in hospitals and non-governmental organisations, and in partnerships with governments and other secular agencies delivering health care. Two key challenges for Christian mission in the global health-care context are then discussed: increasing distance from individuals and increasing pressure not to evangelise. The reasons for evangelicals sometimes appearing to succumb to this latter pressure are considered. Finally, an attempt to resolve this tension is made in the context of Christian calling and the task all Christians have to make disciples, whatever their role in life.

Keywords

Global health medical missions religious missions Christianity Bible

Introduction: what is global health?

‘Global health’ is the latest fashion in health care. Clinicians, academics and policymakers make much of the term, and much energy is spent in pursuing its goals. But there are different understandings of what it actually is (Koplan et al., 2009; Strand and Cole, 2014). The UK government’s definition of global health is typical of a focus on the ‘global’ aspect:

Global health: refers to health issues where the determinants circumvent, undermine or are oblivious to the territorial boundaries of states, and are thus beyond the capacity of individual countries to address through domestic institutions. Global health is focused on people across the whole planet rather than the concerns of particular nations. Global health recognises that health is determined by problems, issues and concerns that transcend national boundaries. (Kessel et al., 2014:7)

This definition stresses the crossing of boundaries, implying the need for multinational cooperation. ‘Domestic institutions’ (such as local hospitals or even health ministries) are unable to meet their population’s needs in isolation. It also focuses on the cause of health problems, implying a focus on preventive health. In one sense, this definition is all-encompassing: it is about people across the whole planet. In another, it is quite limiting: it seems to include only those health issues that do cross national boundaries.

In 1948 the World Health Organization famously defined health as: ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (Grad, 2002:984). If health is itself all-encompassing, including all aspects of individual and social well-being, then it is possible to argue that any health issue might have determinants (however remote) that cross national boundaries, including social, educational, financial, military and other causes. Preventive action to improve health might necessitate intervention in all those arenas. The UK government’s definition of global health could conceivably therefore cover almost any health condition, anywhere, and, moreover, by intervening in any area of life. So, perhaps this utopian and comprehensive definition suffers from a lack of specificity. If everything is global health, then perhaps nothing is global health (pace Neill, 1959).

A leading journal in global health, the Lancet, offers another definition:

Global health is an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasises transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population based prevention with individual-level clinical care. (Koplan et al., 2009:1995)

Although its scope is worldwide, the emphasis on achieving equity in health for all people implies that the focus is on less resourced settings. Its practice is similarly multinational and transdisciplinary, but there are more concrete examples of what this looks like: delivery is not just population-based, but also at the level of individual care. It is not just about prevention, but clinical and academic.

Koplan et al. (2009) see global health as a development from ‘international health’ (focused on medical support from a richer country to a poorer country, for both prevention and clinical care), which itself was a development from ‘tropical medicine’ (focused on individual clinical care in poorer countries, usually by clinicians from richer countries). Global health is seen as more collaborative and less one-sided, more equitable than possibly paternalistic.

Global health includes long-term development work, building sustainable health-care systems, as well as shorter-term disaster relief. It includes advocacy for government-level decisions, as well as teaching and clinical practice in universities, hospitals and clinics. Christian doctors and nurses have been enthusiastic advocates of global health initiatives across the spectrum of its activities. The Christian Journal for Global Health was established in 2014 for research and reflection on ‘global health policy and practice’ worldwide. Its core values include ‘intercultural’ and ‘integrative’ – emphasising the multinational approach to holistic medicine (the physical, mental and social well-being referred to by the World Health Organization). But unlike the World Health Organization, Lancet or UK government, ‘missional’ is a core value too. For Christian global health practitioners, global health is part of Christian mission.¹

Medical mission: a historical overview

God’s people have been involved in healing and health care since the Torah (e.g. Exod. 15:26; Lev. 13:1–14:32; Num. 21:9). Miraculous healing accompanied powerful proclamation of God’s word by prophets and apostles (e.g. Acts 3; 2 Kings 5). And Christ’s earthly ministry saw an explosion of healing (e.g. Mark 1:32–34). James (5:14) encouraged the early church in prayer and anointing for the sick.

Christians have been at the forefront of health care ever since (Grundmann, 2008; Hale, 1995). They have been motivated by Christ’s purpose (e.g. Luke 4:18), example or command (e.g. Luke 10:9); by the practice of the apostles and early church; by a conviction that healing was a sign of the coming Kingdom and a foretaste of the new creation (e.g. Rev. 21:4); and by a desire to be like Christ in their expression of compassion and concern for those in need.

Pagan clinicians had practised medicine for centuries, but their service was for those who could afford it. In ad 259, it was the church that cared for plague victims in Alexandria when no one else would, and it was the monastic movement that established the first hospitals for the poor. Christians demonstrated an interest not just in health, but also in compassionate help for the helpless (Grundmann, 2014; Lavy, 2013).

However, the popular understanding of modern medical mission began with colonial expansion by European countries throughout the world. There were Spanish hospitals in the Americas and a Jesuit hospital in Japan in 1568 (Lavy, 2013). Protestant medical mission took off in the 19th century. The term ‘medical missionary’ was used in New Zealand in 1819, and the Medical Missionary Society, established in Edinburgh, was working in China by the 1840s (Grundmann, 2014; Karpf, 2014). In the hundred years that followed, there were 1500 British doctors in overseas mission, usually working in mission hospitals (Lavy, 2013). In 1945, the British Medical Journal reported that there were currently 900 Protestant missionary doctors, almost half from the USA, and 1200 nurses overseas. Interestingly, it was noted that the number of indigenous doctors working in mission hospitals exceeded that of western doctors. The age of medical mission hospitals run by western mission agencies was coming to an end, at the same time as political decolonialisation. There was an increasing indigenisation of hospitals, as there was with churches. Leadership in health care by medical mission agencies passed to national ministries of health.

The parallel history of western medical mission hospitals with empire and secular medicine was perhaps also reflected in the conflicting motives of missionaries (Grundmann, 2008). Early medical missions were spurred by the evangelical revival (restoring a heart for evangelism) and also by newly discovered medical advances (antisepsis and anaesthesia), which meant that medicine could now achieve meaningful treatment (Grundmann, 2014), as well as by the opportunities afforded by imperial expansion. British Medical Journal (1895, 1923, 1945) commentaries describe various reasons for going overseas: ‘to give a most practical exposition of Christianity’ (British Medical Journal, 1895:847), but also the unique opportunities for ‘the adventure’, for interesting work, the richness of the clinical experience or opportunities for research. Mission expeditions, sincerely seeking to make disciples of Christ and help them become self-sufficient in both church and health care, took advantage of the opportunities given by expanding empires and arguably helped further that expansion; medical mission expanded medical knowledge and shaped its future practice.

If the history of medical mission mirrors the history of western involvement in the rest of the world, it also reflects the development of secular medical practice globally. Until the mid 20th century, medicine was a hospital-based paradigm following a biomedical model of disease, with a focus on cure (DeAngulo and Losada, 2015). This was how medicine was practised in London or New York, and it was how medical mission was done, albeit as ‘tropical medicine’ focusing on finding cures for people with exotic diseases. Western doctors ran tropical hospitals and trained local doctors in newly created medical schools. Missionary medicine was local (and often rural); it was ‘horizontal’: clinicians dealt with all comers and did not focus on one disease or programme (Jansen, 1999).

The second half of the 20th century saw a shift in emphasis to preventive medicine and the use of the term ‘international health’. It also saw increasing involvement by ‘vertically’ oriented non-governmental organisations (NGOs) and government programmes dealing with single health-care issues like tuberculosis or HIV (DeAngulo and Losada, 2015; Jansen, 1999). The shift in the focus of the World Health Organization to community-based primary care (away from centralised hospitals) was heavily influenced by the ecumenical movement (Karpf, 2014). The World Council of Churches and Lutheran World Federation had convened a week-long meeting at Tübingen in 1964 for those engaged in medical mission. It concluded that the church has a specific task to be involved in healing ministry, and established the Christian Medical Commission to engage in appropriate research and coordinate national church-based medical mission (Flessa, 2016; Grundmann, 2014, 2015). In 1974, the director general of the World Health Organization invited the Christian Medical Commission to collaborate on priorities for health care, culminating in the 1978 World Health Organization declaration at Alma Ata calling for a focus on primary health care – the provision of equitable, essential and universal health care for all. The emphasis was on social justice, and the slogan was: ‘health for all by the year 2000’ (Karpf, 2014:21).

The last few decades have seen a shift towards what DeAngulo and Losada (2015: 53) call a ‘health-genic systemic ecological paradigm of comprehensive health’. The focus of this ‘global health’ is on what brings life and health, rather than on what brings disease and death. It is more holistic (and therefore ‘horizontal’), embracing complexity rather than trying to simplify things into vertical silos. This holism is seen in the interaction of health with all areas of communal life (social, political and economic) at all levels (global, national, local and family), paralleling renewed Christian emphases on creation care and involvement in all aspects of life. It is also more holistic in its renewed understanding of people as being bio-psycho-social and spiritual beings. In parallel with a growing movement for ‘whole person medicine’ among Christian medical practitioners (Morgan, 2016), the World Health Organization (1998) also stressed the importance of spirituality in health care in its report on ‘spirituality, religiousness and personal beliefs’. Since then, many other secular medical organisations have also emphasised the importance of spirituality in patient health (e.g. NHS Education for Scotland, 2009).

Christian involvement in global health: where we are now

So, this is the context for contemporary medical mission – a global health paradigm that is global in its geographical and social reach, in its collaborative and multidisciplinary delivery, and also in its holistic understanding of health and humanity. In what ways are Christian health-care workers involved in health, globally, today?

Hospitals

Traditional mission hospitals still exist in many countries. Some of these are co-located with medical or nursing schools. As has been the case since the 19th century (British Medical Journal, 1923), there are varying emphases on the faith commitment and involvement required of employees. Some might expect all senior clinicians or academics to be clearly Christian; some might allow not-yet-Christian staff to work there as long as they are sympathetic to the Christian ethos of the hospital or school. In some, the medical staff concentrate on medical care while evangelism is the responsibility of chaplains; in others, gospel proclamation and teaching is expected from all Christians (Hale, 1995; Hibbs, 2010; Sanders, 2013).

However, it is not feasible for any hospital or college to operate in isolation from the rest of a country’s health-care and education systems. Christian hospitals must (and should) collaborate in health care with various organisations: other local hospitals and clinics, government ministries, and secular and religious NGOs, as well as their ‘sending’ or ‘supporting’ mission agencies and churches in other, usually wealthier, countries (Lavy and Parry, 2014). Many mission hospitals, though, have been forced through government pressure or financial constraints to become fully integrated within the national health-care system, making it more difficult for them to maintain the traditional ethos of a Christian hospital The globalisation of health care, and the growing availability of medical technologies and drugs previously beyond the reach of poorer countries, has meant that the cost of running a hospital is now much higher than might previously have been acceptable. Government ministries and large-scale donors are unlikely to support small hospitals that are not part of an integrated health-care system, and many mission agencies and churches cannot afford the costs involved (Hale, 1995).

The training of doctors and nurses has also become more complex and expensive, with increasing specialism globally. It is no longer acceptable (if it ever was) for rich countries to have specialist paediatric cardiologists and poorer countries to make do with general practitioners. Now that there are national medical schools worldwide, there is little need for mission hospitals to train doctors and, if countries require further training for specialists, it is unlikely that mission hospitals will have the resources to provide this (Grundmann, 2008; Lavy, 2013). As a result, perhaps more medical missionaries now work within the secular health-care system rather than in specifically Christian institutions, both clinically and academically (Lavy and Parry, 2014; Sanders, 2013).

NGOs from the global North

If there is diminishing scope for the traditional mission hospital model, the global health paradigm has given more opportunity for Christian involvement in other ways. The last few decades have seen many more NGOs from wealthier countries of the global North operating in low- and middle-income countries. Many Christian NGOs are involved in development work through advocacy, local development projects, teaching, clinical care or disaster relief. The goal of this work is to help build or maintain sustainable, long-term improvements to health-care systems or delivery. All will need to work in partnerships with secular NGOs or governments. Many might be relatively small scale, unable to make much impact on their own, but can make significant contributions in collaboration with others (Lavy and Parry, 2014).

Christian health-care workers find opportunities for mission within such organisations, but many will also do so in secular NGOs (such as Oxfam or the Red Cross), in the same way that Christian medics are found in both traditional mission hospitals and government institutions (Tomkins, 2016).

NGOs in the global South

But it is not just about the rich North helping the poorer South. In low- and middle-income countries, there are also increasing numbers of community-based NGOs engaged in sustainable health-care development in their own countries. These might be smaller clinics in remote villages or charities focusing on particular health-care issues in that region. Often, these groups are ideally placed (socially and geographically) to implement community-agreed priorities in primary health care, HIV medicine, refugee care or other projects supporting the United Nations’ ‘sustainable development goals’ (Lankester, 2014).

Many of these organisations are faith-based, often part of the ‘temple, church or mosque’ that is present in nearly all communities (Lankester, 2014). They understand their community’s needs and offer solutions from within that culture (Fouch, 2013).

Religious assets

It is notable that these small, perhaps previously hidden, faith-based organisations are now receiving recognition and, more than that, encouragement to play a greater role in the global health endeavour – not just from Christian organisations, but also from the World Health Organization, governments and secular NGOs (Fouch, 2013; Karpf, 2014; Lankester, 2014; Lavy 2013).

An African Religious Health Assets Programme report described the enormous impact of faith-based organisations (or ‘religious assets’) on health-care provision in Africa (Schmid et al., 2008). Up to 70% of health-care services in parts of southern and east Africa depend on faith-based organisations. The World Health Organization took this on board as an opportunity for a renewed emphasis on primary health care (Braley, 2014). The United States Agency for International Development has acknowledged the huge contribution that faith-based organisations have made to HIV prevention (Lavy, 2013). The UK’s Department for International Development (2012) has published principles for growing partnerships with faith-based organisations. A series of articles in the Lancet was published to discuss this increasing role for faith-based organisations in global health (Duff and Buckingham, 2015; Olivier et al., 2015; Summerskill and Horton, 2015; Tomkins et al., 2015).

Future partnerships

In summary, global health is all about crossing boundaries – boundaries between countries, between disciplines and between providers, and even the boundaries that delineate the physical, mental, social and spiritual aspects of a person.

There is growing recognition of both the importance of the spiritual in health care and the role religious organisations have in the provision of health care. Although traditional Christian mission hospitals still have a role to play, the majority of Christian involvement in health care will necessarily be in partnership with secular governments and NGOs. Whether this is individual Christians working alongside non-Christian colleagues in secular institutions or overseas NGOs and local community-based groups working with others of different faiths or none, this is what is on the agenda now; this is what is being encouraged. We are seeing new models for health-care mission and, with them, new challenges and opportunities that need to be explored if we are to be faithful to Christ and his mission for his church.

Challenges for Christian mission in global health

There have always been challenges in medical mission. Perhaps the most obvious difficulties of an earlier generation were those described in the British Medical Journal (1945): ‘Dirty, lonely, unpleasant, uncomfortable service, the mission hospital stands for that’. Medical missionaries in the century before that article was written were often working in isolated areas without the easy flights home that are available now; they had very limited resources in difficult conditions. None of this was unique to doctors or nurses: it was true for many missionaries. For those working in remote mission hospitals today, these issues are less pronounced, though still present to an extent. However, the global health paradigm brings to the forefront other challenges to Christian mission.

Distance and relationships

First, there is often an increased distance between the global health practitioner and the individual in need of help. In the traditional hospital environment, medical missionaries engage directly with their patients – they can care for them medically as well as speak to them about Christ. In a purely academic environment, teaching in a medical or nursing school, the missionary is still engaging with individuals. The teaching of medicine replaces clinical work as their practical service to people, and the opportunities for relational evangelism and discipleship remain.

But global health missionaries may find it more difficult to engage with individuals in this way. Much work is lobbying and advocacy, developing systems of care rather than delivering that care themselves. Much of this work will be conducted at a physical distance from the point of need, especially in the Internet age of email and video-conferencing between people on different continents. Of course, there will always be individuals to engage with face-to-face as well, but these are more likely to be colleagues from one’s own organisation, government officials, health service administrators and staff from other NGOs. These people need the gospel too, but the relationship dynamics are very different from that of doctor to patient, or clinical teacher to medical student. This is not a bad thing; in fact, it could be argued that relationships which are less hierarchical might be more appropriate for relational evangelism. But it is a different thing. Furthermore, the global health missionary is likely to engage with fewer people than the traditional clinic doctor who saw hundreds of patients in a day. Again, this is not a bad thing; and, again, it is reasonable to think that deeper relationships with a few might be more beneficial to gospel work than superficial relationships with many. After all, Jesus chose 12 to spend more time with and, of those 12, he focused on Peter, James and John. But again, it is a different way of doing medical mission, and those expecting the more traditional approach will need to meet these challenges.

Pressure not to evangelise

Second, and more concerningly, there is more pressure not to evangelise. There has always been opposition to the gospel, and always will be. Opposition to evangelism and discipleship in hospitals and medical schools could have come from local leaders and colonial administrators alike, perhaps expressing concern of risking social instability. But, in general, Christian-run hospitals were free to treat patients, train students and speak of Jesus. Opposition could also come from within, particularly from staff with different priorities or understanding of the gospel. Some medical staff might be more concerned to focus on medicine and leave Bible teaching to chaplains, for example. But again, in general, hospitals that were free to select their own staff could ensure that their staff were at least sympathetic to the goal of reaching people for Christ alongside medical ministry. In the global health paradigm of Christian doctors and nurses increasingly working in secular institutions, and increasing partnership between secular and religious organisations, there are significantly bigger challenges to gospel proclamation.

Although there is increasing government and World Health Organization recognition of the importance of ‘religious assets’ in health-care delivery, and appreciation of the importance of religion in motivating people to care for others (Crisp, 2007; Department for International Development, 2012), there is antipathy with religion that expresses itself either in evangelism or in ethical opposition to government policies in health care such as abortion. The Department for International Development (2012:8) described the problems of ‘church and state’ working together, particularly when ‘religious teaching often focuses on questions of behaviour’. While approving the role this (i.e. religion-inspired ethics) played in toppling authoritarian regimes or promoting human rights, the Department for International Development made it clear that, in areas such as contraception, gay rights, religious freedom and several other ‘religious practices’, it was much more contentious. Its solution was, encouragingly, for faith-based organisations and governments to collaborate and explore these issues sensitively. The same concern was expressed more strongly by Messinger (2015) in the Lancet, who described her opposition to ‘proselytising and judging’: ‘faith-based organisations must do more than listen. They also must avoid exploiting our access to these hard-to-reach communities to persuade them of the truth of a given faith or the “evils” of their behaviours’.

In response to concern that organisations were using disaster relief operations to ‘proselytise’, the Red Cross movement developed a code of conduct for humanitarian relief (International Federation, 1994), which expanded on four core principles for humanitarian relief: humanity, impartiality, neutrality and independence (Samaritan’s Purse, 2016). The Red Cross code now includes the following principle: ‘Aid will not be used to further a particular political or religious standpoint’ (International Federation, 1994:3). The code was sponsored by several religious organisations, including the World Council of Churches, the Lutheran World Federation and Catholic Relief Services. It has subsequently been signed by many more, including Tearfund and World Vision (International Federation, 2013), both of which have an evangelical heritage. It has not been signed by Samaritan’s Purse (2016), which wishes to proclaim the gospel alongside its disaster relief. It is unclear whether those who framed the Red Cross code of conduct intended to prohibit any evangelism alongside the provision of aid or just the use of that aid as a tool of evangelism. But it is interesting that Médecins Sans Frontières has also refused to sign the code, perceiving it might limit their role in advocating for particular political standpoints. Whether explicit or not, there is a ‘freezing’ of religious discourse, limiting it to motivations rather than ethical or evangelistic expression. And it seems that some religious organisations in global health are content to go along with this.

Facing these challenges

Neither of these challenges (less focus on individuals and pressure not to evangelise) are big problems to those Christians who understand mission as more about societal transformation than individual conversion. Global health paradigms are much more about ‘bigger-picture’ sociopolitical change than about medical care for an individual sick patient. It is perhaps not surprising that the growth of global health was so strongly influenced by ecumenical bodies like the World Council of Churches. If mission is all that God does to build his Kingdom, and his Kingdom is equated with social justice, then clearly global health would be one part of that mission. This might also imply that whether this is done by Christians or non-Christians, it is still mission.

However, even if global health (seen from the systems and social structures end of the spectrum) is part of God’s work to transform society, without concurrent focus on individuals and on proclamation of the gospel it cannot be the whole of God’s work within health care. As Gisela Schneider, director of the German Institute for Medical Mission, wrote: ‘Medical mission that . . . brings health and wholeness, restoration and reconciliation will cause transformation of people and society and be truly part of God’s mission in this world’ (Scott et al., 2010:13; my emphasis).

Many evangelicals might disagree with DeYoung and Gilbert (2011) that the mission of the church is solely to make disciples. Many would be happy to accept the view espoused by the Lausanne conferences, and implied above by Schneider, that God’s mission is to bring redemption and restoration in society – including politics, law and medicine – as well as forgiveness for sin and reconciliation between individuals and God. And yet, although no evangelical would deny that the proclamation of this latter aspect must be at least part of truly Christian mission, in practice evangelism often appears to be minimised in health care, and especially in global health.

Evangelism in the evangelical medical mission literature

I conducted a brief review of articles about mission published recently in the following Christian medical journals from the USA, UK and Australia, respectively: Christian Journal for Global Health, Triple Helix and Luke’s Journal.² All are owned or endorsed by explicitly evangelical Christian medical organisations. The majority of articles focused solely on health care and related social justice issues. Many made no mention of evangelism, although there were several exceptions.

Scott et al. (2010:13) argued that ‘saving the soul is ultimately more important than mending the body’ and ‘medicine is a means by which communities receiving health care also received something more vital – the Gospel’. Ong (2009) similarly saw mission explicitly as disciple-making, and medical mission as an opportunity for this – demonstrating God’s love tangibly alongside the testimony of Christ. Lankester (2011) described ‘integral’ medical mission as sharing the gospel and working for justice or health care – not one as a means to the other, but both as part of God’s call. Strand and Cole (2014) argued that truly holistic health care must include proclamation of the gospel.

More typically, however, Downing (2015:16; my emphasis) described Christian global health as ‘the overlap of global health activities with Christian motivations, sometimes including evangelism’. He noted that early medical missionaries were often ‘passionately evangelistic’ and concluded that it is suffering and sacrifice that make our practice distinctively Christian in a global health paradigm that is based more on socialism than Christianity. Erb (2017:50) presented another typical report of a discussion on the distinctive value added to our work in global health as Christians: ‘honouring the dignity of the lives of people we support, our ethics, compassion, and holistic approach, as well as the transformative nature of our work and our stewardship’.

Christ’s incarnation and service were often seen as inspirational and exemplary. Deutschmann (2009) saw in Christ’s incarnation our motive for long-term commitment cross-culturally. Another theme of incarnation was the reminder that medicine is an opportunity for us to realise the truth that God is concerned with the body as well as the spirit. Grundmann (2014:12) went slightly further: ‘Medical missions challenge the common conviction that the soul is more precious than the body’.

Several articles described the significant impact of Christian faith-based organisations on health-care development and delivery in low- and middle-income countries (e.g. Fouch, 2013; Lavy and Parry, 2014). Lankester (2014), however, stressed the importance of all faith-based organisations, not just Christian ones. He sees our mandate to serve the world compassionately and creatively, to demonstrate God’s ‘saving health’ (Ps. 67:2, KJV), as part of what it means to see God’s Kingdom come. But perhaps inconsistent with his earlier description of integral medical mission (Lankester, 2011), he states that doctors from both Christian and other faith backgrounds have the privilege to bring this about.

Is medicine special?

It seems that in health care, and perhaps especially now in global health, even some evangelical Christian health-care practitioners are willing to see evangelism as an optional extra to compassionate, incarnational, healing and social transformation ministries. If it is not that we think evangelism is unimportant (or we would not be evangelical), why is this?

Perhaps for some it is simply the influence of secular pressure, and a pragmatic willingness to accept government guidelines on proselytisation for the ‘greater good’ of being allowed to work in global health projects. Perhaps for others it is a matter of ‘division of labour’. Some will do health care; others will do evangelism (Sanders, 2013). Regardless of whether this attitude is biblical, it might be a pragmatic solution in a mission hospital setting where the clinical practitioner, swamped with the medical workload, could rely on the chaplain or others to focus on ‘spiritual’ work. However, it makes less sense where there is little surrounding Christian mission context, infrastructure and staff. Global health involves Christians in often entirely secular environments and institutions. Perhaps instead, local churches, entirely separate from the global health endeavour, could be seen as the providers of the ‘spiritual’ work. However, in many situations there are no local churches.

Either way, doing global health without evangelism is still described as ‘mission’ by many evangelical Christian doctors. A possible explanation is that we think that medicine is something intrinsically and especially Christian. The UK’s Christian Medical Fellowship website states:

CMF’s [Christian Medical Fellowship’s] ministry is based on Jesus’ instructions to his disciples, as reported by Luke, the first known Christian doctor: to preach God’s Kingdom and to heal the sick (Luke 9:2).

These instructions are further expanded in Jesus’ Nazareth Manifesto (Luke 4:18, 19) where he describes his mission as one involving preaching, healing, deliverance and justice. (Christian Medical Fellowship, 2020)

Luke 9:2 is a specific command to specific disciples (the 12) at a specific time; the context does not suggest that this is a command for all disciples for all time. If it is, we have certainly ignored the next verse, which forbids taking food or money with them – somewhat ironic in view of UK doctors’ salaries. But, more worryingly, if the healing commanded by Christ is indeed the sort of healing that doctors do, then it would appear that only doctors can fully obey Christ.

Instead, the healing commanded was, like Christ’s healing ministry, miraculous. In the power of God’s Spirit, it was a ministry for fishermen and tax collectors. Whether such a healing ministry is enjoined on all or some Christians now is a different question, but whatever one’s views on charismatic healing gifts, few would restrict them to people with medical degrees.

If Luke 4:18–19 is literally about prisoners and blind people, why is Jesus not actually recorded as setting any prisoners free? And why are other acts of healing beyond the restoration of sight not mentioned? In context, the passage is more likely to be a metaphorical description of the holistic freedoms that Christ brings: freedom primarily from sin and death, but also restoration of all the fulness of new life, including but not restricted to health. Jesus’ healing ministry was a demonstration of this new creation exploding into this world, but both his acts of healing and those of his disciples were a foretaste of a future perfection that is not yet fulfilled. They were also opportunities to demonstrate the compassion of God for suffering people. Yet, as Luke the physician records, Jesus was explicit even in the midst of crowds seeking healing from him, that his purpose was preaching (Luke 4:40–44). His plan was to die (Luke 9:22), and his plan for his followers was to proclaim the forgiveness that his death offers those who repent (Luke 24:46–47).

If we forget this priority, it is all too easy to slip into an unbiblical understanding of what healing is and is for, and equate it with the practice and purpose of physicians. If the practice of medicine really is the healing that Christ seeks for the world, then we not only elevate the salvific significance of secular medicine, but also denigrate the ministry of the vast majority of Christians who are not medical.

As we celebrate the 500th anniversary of the Reformation in Europe (Reeves, 2017), we would do well to remember Luther’s trenchant refusal to accept a sacred–secular divide between priests and laypeople (Jenkins, 2014). In modern evangelical circles, it is all too easy to create a ‘holy hierarchy’ of ministry in its place, with doctors, nurses and teachers – those involved in social justice work – near the top and other Christians bringing up the rear. But medicine is not ‘specially’ Christian, and nor is global health ‘specially’ mission.

Opportunities for Christian mission in global health

So, how do we resolve these tensions? How do we enthusiastically support Christian involvement in global health without falling into the dangers described above?

Christian calling in all areas of life

We need to recover a biblical understanding of work, indeed of ‘all of life’, which encompasses politics and plumbing, housework and health care, music and marriage. The approach of Lausanne to mission (e.g. Stott, 1975; Wright, 2006) was that God is not interested only in forgiving sin, but in temporal restoration and redemption, in social justice and healing. Mission is like two scissor blades: one is disciple-making; the other is restorative social action (Chester, 2004). The irony is that this fails to recognise that God wants his people to do much more even than that. It runs the risk of a new sacred–secular divide, between those who do social activism for a living and the rest. Kirk’s (1994) missio ecclesiae instead saw mission as all that God calls his people to do; it is creative as well as redemptive. This is more holistic, and helps us more readily see that all of life is sanctified in Christ.

However, neither model adequately prioritises people’s eternal relationship with God. Jesus’ mission priority was to restore people to God: it is why he preached, died and commanded his disciples to make disciples. But this should not result in another sacred–secular divide. It is not that some Christians (the elite) make disciples and others do the rest of the ‘all-of-life’ tasks through which God keeps his world going. Instead, in whatever role in life God has called us, all of us are to make disciples. If we are all called to be disciple-makers, and if there is no ‘holy hierarchy’ in the many other different callings we have in the rest of our lives, then there is no sacred–secular divide.

This idea of ‘call’ is explored in 1 Corinthians 7:17–40. Everyone has a different role, according to the life God has assigned them: these different callings might be our nationality (Jewish or Gentile), marriage (married or single) or work (slave or free). None is intrinsically superior to another; there is no inherent need to seek a better calling. But what does matter most is one’s calling to Christ, which is common to all of us, and so much more important than the temporality of this present age (1 Cor. 7:31). So, Paul explains that what should shape our desire to change our earthly callings (our marital status or our slavery) is those eternal priorities: what makes one more devoted to God.

Within those temporal callings, though, however difficult they might be as the wife of an unbeliever or a slave to a harsh master, we are to live as though serving Christ (Col. 3:18–24). All aspects of our lives are service to him; there is no hierarchy. Whether you are a galley slave in ancient Rome or a global health practitioner in the 21st century, what matters is whether you are working as for the Lord. But again, although there is no hierarchy between those roles, there is a category difference between the roles, and the relationship with God that gives those roles dignity and value. Whatever you do, it is all equal in Christ. So, the priority – both logically and eternally – is being in Christ, which is why disciple-making is central, and not just the other blade of the scissors. Whatever we do or whoever we are, we are all called to make disciples – to seek the salvation of others, in imitation of Christ, to the glory of God (1 Cor. 10:31–11:1).

Making disciples in all aspects of life

McGavran was famously concerned that all the other activities commonly involved in mission (teaching, medicine, etc.) could push out the centrality of disciple-making (Hunter, 1992). If we see disciple-making as just one activity among many good things that Christians can do, then this is likely to be the case. As observed earlier, Downing (2015) implies this in Christian global health activities ‘sometimes including evangelism’.

Evangelicals have often been accused of proclamation of the gospel without accompanying good works: ‘We have not been called to an “either/or” gospel but rather a “both/and”’ (Palmer, 2015:455). In medical mission, however, we are in danger of losing the proclamation altogether. Mission should be the proclamation of the gospel in the context of living out the truth of that gospel in loving deeds, in order to make disciples. This is the mission of the whole church. The church’s mission is not health care or social justice or better prisons. It is making disciples in the context of loving obedience to Christ and service to others. And that loving service will vary from Christian to Christian. For some, it will be global health care. It is a reminder that the work we do, whatever we do, should be an act of loving service. It is very easy to do medicine in an unloving way, especially when at a distance from the suffering patient. But wherever God has put us, he has given us opportunities to show love for others.

In a sense, then, the mission God has given an individual Christian is everything he has called that person to do – for some Christians, their mission includes being a wife, running a company or coaching a sports team. Their mission is to make disciples in those contexts; they are called to make disciples alongside their home, work or leisure activities. Christians in global health care are right to say that their mission is in global health: that is where God has put them, to make disciples in the context of loving service in global health. This understanding is perhaps more in keeping with the ‘business as mission’ model than with the traditional view of medical mission (Lam, 2015). It sees medicine not as the mission itself, but the context for mission. Nor does it see medicine as a means to an end – as though the only reason we care for people is to get them to listen to our message – but as an integral part of our individual calling to love others in medicine. As Brand writes:

medical missions today, in following the footsteps of our Lord, cannot but be concerned with the tremendous physical need in the countries where we work. Yet we have to remind ourselves that the real reason we are there is not to tackle illness . . . but to meet men and women with the love of our Lord Jesus Christ. (Brand, 2014:27)

In this way, it is easier to see medical mission happening in secular organisations as well as in Christian ones. As Sanders (2013) writes, you might lose the title ‘missionary’ but you have the same calling. If God has placed you in a government hospital with no Christian colleagues, that is the context for your mission to love others and make disciples. It is easier to see how global health work in advocacy, never seeing an actual patient, is just as much medical mission as working in a traditional mission clinic. If the people God has given you are other health-care professionals and government officials, rather than patients, those people are the mission field God has given you in the context of your chosen field of medicine.

Conclusion

Christian health-care professionals should be enthusiastic about the opportunities for mission brought by the current emphasis on global health. However, there is significant risk that proclamation of the gospel is ignored amidst the planning and delivery of health care. There is also significant risk that health-care professionals elevate health care above the many different jobs and roles God has called his people to do, creating an unhealthy ‘holy hierarchy’ with medicine at the top.

The practice of modern medicine should not be understood as the equivalent of Christ’s healing ministry. The mission of the church as a whole is not medicine. The mission of the church is to proclaim the gospel in the context of living out the truth of that gospel in loving deeds, in order to make disciples. And God calls each Christian to a different context in which to work out that mission.

Global health care should not, in isolation, be called ‘mission’. Instead, Christian global health-care practitioners should see health care as the context for their mission to make disciples and a wonderful God-given privilege to demonstrate the love of Christ in a practical way.

Footnotes

Acknowledgements

All opinions expressed in this article are the author’s own.

Declaration of conflicting interests

The author declared the following potential conflicts of interest with respect to the research, authorship and/or publication of this article: I am a medical doctor and have worked for global health programmes in several countries. I am currently chair of the UK Royal College of Emergency Medicine’s Global Emergency Medicine Committee.

Funding

The author received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Giles N Cattermole

Notes

Author biography

Dr Giles Cattermole graduated from Oxford in 1995 and trained in emergency medicine in Wales. He has degrees in physiology, ethics and theology. He now works as an emergency medicine consultant in London and is also the London Team Leader for UCCF: The Christian Unions. Giles holds honorary associate professorships at the Chinese University of Hong Kong and the University of Rwanda, and is an honorary senior lecturer at Queen Mary University of London. He is chair of the Royal College of Emergency Medicine’s Global Emergency Medicine Committee. He was previously Head of Student Ministries at the Christian Medical Fellowship.

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