In August 1976, at age twenty-two, I left the U.S. for Nicaragua. Fresh diploma and nursing books in hand, I truly wanted to follow Christ's call to bind up the wounded, heal the brokenhearted and preach the good news. My motives were mostly sincere; however, pictures of clinics on beautiful beaches and the lure of experiencing new cultures made the supposed sacrifice quite palatable. Who wouldn't want to be a nurse on a tropical beach, saving villagers while in God's service?
I did not know that there were ailments awaiting me that do not appear in nursing textbooks, that missionary nurses were no longer needed on that picturesque beach or that training, not direct treatment, was the primary need. I was also entering a part of the world poised for war. My excellent nursing education and missionary zeal could not prepare me for what lay ahead. I took many useful characteristics and tools with me, but I also carried along beliefs, attitudes and ignorance that hindered my service.
Our worldviews, or the way we think about the world, are shaped by our culture and shared at some level with Christians and non-Christians. These views are largely unconscious, but powerful. Two worldview perspectives predominate among middle class Caucasian North American nurses. 1) Western medicine is often the only lens we use to view health in any setting. 2) We are unaware of the power that our race, wealth and nationality give us, while at the same time we accept the unspoken label of being “the great white hope.” These assumptions may keep us from being effective missionary nurses in international settings.
I Reliance on Western Medicine
I discovered my own trust in Western medicine during an incident in my first year in Nicaragua when a fourteen-year-old girl with severe anemia secondary to a massive hookworm infection came to our mission clinic. Her parents had finally decided to seek medical help for her weakness and carried her in a hammock for four hours to reach the clinic. Antonia was going into shock when they arrived. We determined that she was dangerously anemic and made immediate plans to get her to the bus scheduled to leave shortly for a town three hours away where there was a hospital. We had neither IV supplies nor any transportation at the clinic. Antonia needed treatment for shock, and a blood transfusion.
We treated her as well as we could and quickly took her down the hill to the bus. To our dismay, the bus driver refused to take her. “No,” he said with one look at her, “she'll die on the road and then we will have to bring her back.” We were adamant; everything possible must be done to save this girl—no one should die from hookworm infection. We used our power as the foreign health care providers to muscle our way to the back of the bus and sit there with the mother and child.
Antonia died before the bus even started the trek to Jinotega. We carried her body into the nearby church and laid her on a bench as the father made arrangements to carry her back across the mountain to bury her at home. We were stunned. How did the bus driver know? We were the health professionals, but we did not or would not recognize the surety of this death.
A missionary friend from Africa once related how Africans blend Western medicine ideas with their own worldview, in which the spirit world plays an active part in their daily consciousness. He told how missionaries were eager to use microscopes to show Africans the parasite that causes malaria to dispel the belief that it is caused by spirits or by a relationship problem. The Africans were duly impressed and said, “Yes, we can see now what causes the malaria in a person. But tell us, what causes the mosquito carrying that malaria to bite you and not me?”
Although North American Christians generally believe in a spirit world, we are not accustomed to thinking about daily interaction with that world. We want scientific explanations for every ailment. However, as science progresses, we are learning that there are indeed connections between mind and body. We know that prayer changes things, both from our experience and from scientific research. The field of psychoneuroimmunology may someday help us understand why, in scientific terms, we get bitten by the mosquito. In the meantime, we should listen carefully and not be too quick to write off local explanations for illnesses or predictions for health or illness.
Western medicine, based on the scientific method, has saved countless lives. However, we cannot rely completely on one way of viewing how things happen in God's world. God works in many ways. We cannot assume that the way we know is the only way.
“The Great White Hope”
In 1885, Josiah Strong of the American Home Missionary Society wrote: “God in his infinite wisdom and skill is training the Anglo Saxon race for an hour sure to come…. This powerful race will move down upon Mexico… and South America, out upon the islands of the sea…. God is preparing in our civilization the dye with which to stamp the nations… and he is preparing mankind to receive our impress.”1
While few Christians would use these words today, the image is subtly reinforced each time there is a picture in print or on TV. The pictures we bring home from short-term medical missions usually show lighter-skinned North Americans offering food, water or medicine to a darker-skinned citizen of a poor country. This is compounded by the underlying belief that we have the answers, and they have the needs.
There are many needs, and we must not discount them. However, when North Americans, particularly whites, go to a poor country, we must recognize the privilege and power we carry with us and how that may affect our attitudes and those of others. I have seen this world-view damage short- and long-term mission work. Missionaries may come with expectations of better accommodations than the local situation can support, of nationals dropping what they were doing in order to make it possible for the North American to serve, or of ignoring local suggestions on how to set up a short-term clinic or long-term health program.
The power that comes from being a white North American can be used positively. There were times when we used that power in Nicaragua to get access to hospitalization or other needed services for our poor, powerless patients. This semester a nursing student in my community health clinical used that power to help a Hispanic immigrant obtain a social security card that had previously been denied. The woman was then able to get a job. The power we hold is not always color-related; it may be professionally-connected and certainly nationality-connected. But it is power. The existence of that power can be used to empower those whom we say we are helping, but it can also disempower them.
We must look to Jesus as our example in overcoming this worldview. Philippians 2:4–8 states: “Let each of you look not to your own interests, but to the interests of others. Let the same mind be in you that was in Christ Jesus, who, though he was in the form of God, did not regard equality with God as something to be exploited, but emptied himself, taking the form of a slave… he humbled himself and became obedient to the point of death—even death on a cross.”
Millions of dollars are spent to send North American nurses and doctors to developing countries on short-term missions. They usually collect medicines and supplies to carry with them. Often they provide several days of clinic consultations, treatment and surgery, working long days and seeing many patients. In addition, many of those groups also expect to do health education or evangelism but cannot communicate with the people they hope to help. Do they do more harm than good? With the emphasis on evidence based practice, where is the evidence that these nursing practices are effective? Consider the following aspects of short-term missions.
—Money. The money spent during a short-term medical mission could cover the salaries and education of thousands of underemployed medical professionals in the countries those North Americans visit. A Latin American pastor commented to me that the travel costs for one short- term volunteer could pay the salary of someone in his community for a year. Then he said, “But it is necessary that they come. Our situation will not change until the U.S. changes policy toward developing countries. And that will not happen until the U.S. churches are truly converted. So let them come.”
—Medicine. Medicines collected for these trips are often samples or specialized medications recipients cannot afford to continue to take once the supply runs out. Sometimes they take more time to process than they are worth. While working in El Salvador in the early 1980s, we were asked to come to the local hospital to sort through and translate labels for about fifty three-foot-square cartons of donated medicines. It appeared as if someone had gone through pharmacy shelves about five years earlier and had simply pulled off the bottles into the boxes. There were all kinds of meds, including lots of laxatives (rarely needed in countries with a high population of parasites) and bottles of homeopathic remedies with only numbers on them and cases of extra-strength Tylenol. We soon realized that this was the aftermath of the Tylenol scare, where several bottles laced with cyanide were discovered in the U.S. The hospital administrator had also made that connection and wondered if they were safe to use. We decided the benefit outweighed the risk. The Tylenol was well used, and the companies got a tax write-off for their donation, but local health personnel felt dumped-on and used.
—Nursing student exchanges. Increasingly, schools of nursing are participating in international experiences, particularly in poorer countries. Sometimes the arrangements are made when a faculty member has a personal connection with a local clinic or school of nursing. Generally there are positive feelings about these experiences on the part of nationals, but there are unintended consequences.
In a recent qualitative study of relationships between local and international organizations, several of these consequences came to light. One of the most poignant interviews in this study took place with a resident of a poor barrio in a Central American city. In responding to a question about how the people from the outside respond to the community needs, the woman noted, “We would accept whatever they want to give us or whatever they wanted to do. We have to consider that our situation is not that easy and that we must accept God's help in whatever way we can get it.” It did not matter what the aid was, they assumed they could use it. Other people have stated that they need to endure many indignities in order to get a few things they need from the well-meaning visitors.
The involvement of North American nursing students presents a challenge to the community and to the work of the national nursing students in particular. A community respondent remarked, “When (international) students come, they come with different values and different ideologies than the people here. But they can persuade people because they have things and give things, and they help with medications. The national nursing students have to persuade people with their words, since they have no other resources. A national faculty member expressed similar sentiments. The international students give so many things that it makes it hard for our students. They have to beg for things the families need in the barrio. They have to figure out how to help.”2
Context for International Nursing
Nurses who serve in international settings must be “wise as serpents and innocent as doves” (Mt 10:16). We need to be aware of world news and dynamics from a variety of viewpoints, including alternative news sources and various trusted contacts in the country where we work. There are three broad changes or transitions that influence needs and opportunities in the international health context.
Economic transition involves the move to a market economy in developing countries. That means countries are less able to spend government money on health programs, so the gains that were made in the last twenty years may be lost. At the same time, health care expenditures are increasing. Government clinics are stretched beyond imagination. Community development projects may be cut or postponed, leaving citizens without water or jobs.
Political transitions, including pressure to democratize, are the second factor influencing international health. Along with the worldwide pressure to increase citizen participation in health care decisions comes instability and violence that occur in many places. Nurses may be increasingly needed to care for displaced persons within their countries or refugees who have fled violence. Nurses will be caring for people with war injuries, as well as providing rehabilitation and psychological trauma counseling.
Epidemiologic or health transition issues, involving changes in morbidity and mortality trends in developing countries, affect health care. These include increasing longevity, antibiotic resistant diseases and emergent diseases. This changing health context is further characterized by a combination of accumulated challenges and emerging challenges.3 The health care system must respond to these challenges in populations and institutions. For example, the health care system of any developing country must deal with malnutrition (a long-term, or accumulated, population challenge), HIV/AIDS (an emerging population challenge), poor technical quality of diagnostic services (an accumulated institutional challenge) and cost escalation (an emerging institutional challenge). Nearly all the problems of the past are present, along with new ones that affect both developed and developing countries. The combination of these accumulated and emerging challenges present a formidable task for developing countries in planning health services.
All this to say that the context for missionary nursing is different than it was twenty-five years ago. However, there are niches for nurses. There is no one way to serve as a nurse in an international setting. Some settings require direct service, others teaching, research, funds or accompaniment. We do not need to stay home because we are not needed or because we might “do it wrong!” We can find appropriate and effective approaches to the needs.
In Luke's Gospel, Jesus provides a prescription for missionary forays into new places. Luke 10:5–9 has been a guide to many on this journey. “Whatever house you enter, first say, ‘Peace to this house!’ And if anyone is there who shares in peace, your peace will rest on that person; but if not, it will return to you. Remain in the same house, eating and drinking whatever they provide, for the laborer deserves to be paid. Do not move about from house to house. Whenever you enter a town and its people welcome you, eat what is set before you; cure the sick who are there, and say to them, ‘The kingdom of God has come near to you.’”
This passage seems to direct us to interdependent relationships before all else. We must be dependent on those whom we serve. We are not told first to see how many eye surgeries we can do or how many parasite medications we can distribute. We are first to accept our hosts' hospitality, including food and lodging. This would seem to exclude both separate missionary compounds for longer-term missionaries and well-equipped hotels for short-term participants. We have a dreadful fear of being dependent on those whom we serve. Perhaps that has more to do with our own spiritual walls than a real desire not to inconvenience or burden our hosts.
I decided to live by a rather literal interpretation of the command to “eat what is set before you.” Having been embarrassed when foreign visitors, fearing illness, would not eat in the homes of nationals who were my friends, I decided that I would eat what was set before me and that what happened was God's responsibility. Washing fruits and vegetables in my own home or buying questionable food in outdoor cafés was my responsibility. In over twenty-five years I have rarely gotten sick from food offered in homes.
Next, we are told to get around to the healing and to the telling about the kingdom. By then, you have a better understanding of the needs, the culture, the national context and how to best go about the healing and the telling without relying solely on the scientific method or misusing your power as a North American. In the meantime, you have been ministered to as well. Humble vulnerability coupled with the commitment to relationship are the keys to any missionary nurse's effectiveness for the kingdom.
Nurses can provide life-changing, authentic service. There are marvelous examples of authentic approaches, relationships and service. One nurse who works long term with a church relief and development agency teaches several courses in a newly developed master's program in nursing. There she is able to support the excellent faculty as they work with fewer resources than any faculty member in a developed country could imagine. She also volunteers several days a week as a nurse practitioner at a clinic in a squatter settlement, working alongside a local doctor and lay health promoters. In both settings, she got to know the persons involved and began her involvement when the relationship and need coincided.
Sabbaticals or summer assignments are marvelous opportunities for nurses to participate with partners in international settings. The Presbyterian Church supported a Canadian nurse as a visiting professor in the nursing school of a Central American university during her sabbatical year. She was able to teach, assist faculty and be a supportive presence at this church-affiliated school. The school found her contacts with supporting persons and agencies in the north particularly valuable. Schools of nursing or hospitals in developing countries often need someone to provide training for specialty areas such as pediatric intensive care or burn care. Translation is often a challenge, but it can be overcome.
Other nurses work with local and national health planners to prepare materials for training and enhancing health care delivery. Primary Health Care, a philosophy of delivery developed in the 1970s, remains a useful method. It emphasizes including the community in decision making, attending to economic needs in communities (such as job creation) and doing health promotion at the local (primary) level with lay health promoters. Missionary nurses have developed many lay health promoter manuals and other health education materials.
Some who participate in short-term mission are careful to return to the same place with local contacts that provide direction for the best way to maximize the human and material resources. Frequently these health professionals will not participate unless there is a national partner working alongside of them receiving training and providing cultural guidance.
As you consider serving in an international setting, ask: Why do I want to go? Where does the call come from? How should I best prepare? Going on a short-term medical mission experience because of guilt, pressure from others or a quest for adventure usually does not result in a good experience for the recipient or the donors. But if you truly feel God's call and want to respond faithfully, you will find a place to serve where your gifts can be used. To understand primary health care, community development, anthropology and the history of the region where you will serve—study well.
The mandate to go has not changed. All parts of the globe face serious needs. Consider the call. If God is calling you, then go, stay, eat, heal and tell the Good News.