Missionary or Neighbor?
Missionary or neighbor? It’s an interesting question. Do we work with underserved people as missionaries reaching down to serve poor people in a bad neighborhood? Or are we moving into a poor neighborhood to be in solidarity with the people there and work in healthcare as members of their community? We could phrase it differently: do we go to an underserved neighborhood as missionaries bringing good quality healthcare? Or do we simply move to a neighborhood and get a job there in a clinic?
It is difficult to enter these discussions on the way we relate to those we serve without looking at some assumption —assumptions that have gone unchallenged by either side. And those two sides are familiar: the compassionate conservative wants to serve patients as a missionary; the compassionate liberal wants to be in solidarity with patients as a neighbor. The sensitive conservative struggles to not blame the difficult patient; the responsible liberal struggles to not just excuse that patient. Both want to empower him and her through education. Both believe passionately in biomedicine.
That belief in biomedicine, the bedrock that underlies both, comes with several assumptions:
- When natural healing systems fade, we must create artificial healthcare systems. Those systems are like infant formula: “as good as” breast milk, and therefore they often supplant it.
- Health can be attained by the use of commodities, things that we produce and buy. These commodities (like medicines and lab tests) upstage things we don’t buy – like activities and attitudes.
- Emphasizing personal responsibility for health is our job, while addressing socio-politicaleconomic structures and systems that destroy health is someone else’s. Whether we celebrate it or bemoan it, these two are separate: we end up encouraging personal responsibility without reference to irresponsible structures.
- Individual health is best understood and maintained by a mathematical analysis of risk in populations. And in the spirit of “ounce of prevention”, we treat risk as aggressively as disease itself. Risk becomes a disease, and all those with risk become patients.
- Prevention is something the medical system should do – implying (though denying!) that people are dependent on us for prevention.
- Chronic disease care—that is, life-long drug use to manage a disease—is appropriate for all people with those chronic diseases. The impressive failure rate of drug adherence, sometimes up to 50%, rarely leads to a questioning of the model being offered. Instead we fall back on personal responsibility—now subsumed in phrases like “patient education” and “patient empowerment”.
- Evidence (usually numerical) should determine all that we do; therefore, whatever we do must be proven to produce results.
Underneath all of these assumptions is the belief in biomedical science as the foundational method of deciding what to do in healthcare. Biomedicine, in this area of our work, is sovereign, whether we are conservative missionaries or liberal neighbors. Creating systems, producing commodities, analyzing risk, producing evidence of effectiveness—all of these are tools and products of biomedicine. If a product is made or a result arrived at by this sovereign power, we cannot challenge it or ignore it. Most of the time we see no need to challenge it—until we confront those areas where biomedicine is not very successful.
Biomedical approaches don’t always work very well in poor populations (who often can’t afford them) or among oppressed people (where oppression of any kind limits a person’s “responsibility” or ability to comply). Biomedicine has little to offer when a patient’s disease has primarily economic or spiritual roots. Yet where biomedicine does not work well, its response is either to blame the victim (they did not carry out their part as instructed), or to claim that further research will eventually solve the problem with more of its products. Rarely is the problem laid at the foot of biomedicine itself; rarely do we question whether biomedicine is on the right track in its approach. It is, after all, sovereign.
This is odd for those of us who claim another Sovereign, who may even claim that it is precisely because of that Sovereign that we have learned and practice medicine. We may see no conflict between them, but we should not underestimate biomedicine’s claim of sovereignty. Merriam-Webster’s dictionary says, “‘Sovereign’ stresses the absence of a superior power and implies supremacy within a thing’s own domain or sphere.”1 That is an accurate claim for the scientific method within medicine. Can we live with that claim?
Biomedicine is like the foreign people Israel was always encountering: the Israelites were to welcome them into their midst, but never serve their gods.2 If we see no conflict between the sovereign claims of biomedicine and the Sovereign God, we have likely chosen one or the other. Jesus was clear: we cannot simultaneously serve two gods. We can welcome medicine among us; we can make use of its products and methods; we can even celebrate its good. But it is the unchallenged assumptions noted above that begin to expose biomedicine as sovereign.
And now, having looked at those assumptions, we are finally ready to return to the question of missionary or neighbor. Consider both words. A neighbor is someone who lives nearby. There are good neighbors and bad neighbors, warm and cold neighbors, helpful and selfish neighbors. I think it is wise that we be neighbors with those who are our patients, because in living nearby we know their context better. But just being a neighbor is not enough.
A missionary, on the other hand, is one sent; “mission” comes from a Latin word meaning “to send”. Being a missionary implies having a task or carrying a message. If just being a neighbor is not enough, perhaps we need also to be missionaries. But what is it we are sent to do? What is the message we are carrying? This, I think, brings us to the heart of the matter. As with neighbors, missionaries can be good or bad. There are liberating missionaries and condescending missionaries, helpful and annoying missionaries. And so much depends on the message we are carrying. If we are carrying a message of doctrine, whether evangelical or biomedical or Catholic or personal responsibility or free enterprise, we are in danger of being annoying, of not being able to really listen to our patients. There is only one message that is free of this danger, and that is Love.
But we cannot carry a message of Love; we must become Love. And now our Sovereign becomes clear. Love is not an artificial system; it is not a commodity; it is not made clear by analyzing risk in populations; it is not evidence-based. Love means utter dependence on God and a crucifixion of our own will. Then Love is free to be a good neighbor and a liberating missionary, using all the benefits of biomedicine but never worshipping it.
Ray Downing, MD is a family physician, writer and educator who lives and serves in Webuye, Kenya. He has authored several books including Death and Life in America: Biblical Healing and Biomedicine, Suffering and Healing in America: An American Doctor’s View from the Outside, and The Wedding Goes on Without Us