COMMENTARY
Raymond Downinga
a MD, Senior Lecturer, Department of Family Medicine, Moi University School of Medicine, Kenya
At the beginning of his many dramatic proposals for living humanly in the modern world, Ivan Illich first addressed the Church. Better known for his counter-intuitive views on transportation, education, and medicine, Illich began his career as a priest-educator in the Catholic Church, spending over a decade educating would-be missionaries to Latin America. In 1967, addressing an Anglican consultation for social issues, he declared that the time had come for the Church to withdraw from its current role in third-world development and focus on what he called “the annunciation of the Gospel.”1
Mission had, of course, always been about the gospel, but the role of “development” followed closely. How could you preach to people who were hungry or sick? And how could they read the Bible if they were illiterate? There were very good reasons why the church broadened its mission. Medical missions were one of the early forms of development, and medical missionaries in the 19th and 20th centuries recorded their justifications for their expanded roles. Though we no longer discuss, or are even aware of, these archaic rationales, they remain disturbingly consonant with our contemporary foundations for mission institutions.
In 1842, Daniel MacGowan, a young doctor headed to China as a medical missionary, gave an address in New York entitled “Claims of the Missionary Enterprise on the Medical Profession.”2 He was speaking as a doctor, though from the perspective of missionaries, asserting their need to embrace medicine. And he was clear about the link: speaking of the physician, he said, “It is his province to assuage human suffering, in all its varieties and aggravations, and, in imitation of the Saviour, ‘to heal all manner of diseases.’”
Then he suggested the source of some of those diseases:
… many regions of the pagan world are at this time enduring fearful miseries, which they trace directly and undeniably to their intercourse with our commerce and our civilization… Here is a vast amount of wretchedness produced by civilized man. 2
— a frank confession. Therefore,
… as civilized men, we, by our skill and experience, should strive to alleviate, nor is it too much to say, that we have it in our power in a measure to save some of these races from entire annihilation. 2
— a solution even more grandiose than his mea culpa.
Even before scientific medicine had much to offer, this young doctor saw the potential; he unwittingly predicted the yet undeveloped power of the medical profession. Illich, 125 years later, suggested that, in the name of announcing the Gospel, we relinquish this kind of power.
Then, in 1886, in Medical Missions, Their Place and Power, John Lowe presented a view of western civilization much less critical than MacGowan's.3 Among “the heathen,” Lowe writes, “the arts and usages of civilization are unknown” and, therefore:
… no humanizing influences are at work… the sick are uncared for, or treated with barbarous cruelty… the aged and infirm are counted a burden, and either perish from neglect or linger on in misery.3
Yet ironically, his conclusion mirrors Illich's:
Under circumstances such as these, what can the missionary do? 'Preach the Gospel,' we say, for the 'glorious Gospel of our blessed God' is the one only panacea for all the world's miseries. 3
He should have stopped there. But he continued:
Yes, the Gospel is the 'power of God' — the power which has made Britain a land of greatness, intelligence, and influence beyond any other nation on the face of the globe. It is the power which, again and again, has broken the arm of oppression and tyranny, and, dispelling from the minds of millions the dark clouds of ignorance and superstition, has raised the beggar from the dung-hill and set him among princes. 3
The colonial project which Britain was just then beginning in Africa would show Lowe to be a false prophet.
In 1912, a Victorian lady named Elma K. Paget published The Claim of Suffering: A Plea for Medical Missions.4 It exemplifies a subtle shift from the saviour of souls to the succorer of bodies. Citing the example of “The Great Physician,” and noting 250 doctors who had signed an appeal on behalf of medical missions, she explained her title: “medical missions relieve an unspeakable amount of human suffering due to the ignorance and quackery of native doctors.” She then continued the argument Lowe had drawn.
A cloud of despair seems to hang over the non-Christian races and to render them helpless if they are overtaken by misfortune or calamity… To the Christian, pain may become a factor in man's moral, intellectual, and spiritual life; we do not deny its existence nor underrate its sting, but we seek with confidence to use it and in due time to conquer it. So we believe ourselves to be by God's will masters of our destiny, and acting on this assurance we have seen disease retreat from territories where hitherto it has held supreme. 4
She grants the role of suffering as a potentially positive “factor” in a Christian's life. But Paget does not mention sharing in the sufferings of Christ or following Christ's example of suffering. Her view is far more triumphalist, with us ultimately becoming “masters of our destiny,” an idea that comes more from the poem Invictus by William Ernest Henley than from the Bible. The claim of suffering on us, she says, is not to share it but to eliminate it.
Now we may take issue with some of the Victorian analysis above. Was there really such lack of care and concern for the ill, such wretchedness in the so-called heathen lands? How many of those approaches were simply culturally different from the Europeans’? How much was simply sensible use of the resources they had? Or again, to what extent was our western civilization really built on our Christian faith? MacGowan at least admitted his view that some “wretchedness” was due to our civilization more than that of the “heathen.” And as for the claim of suffering on us, as noted above, Paget and others could see only that it needed to be eliminated, even though the Biblical account was far more nuanced.
Nevertheless, there is much above to which we still hold: that Biblical ministry is both physical and spiritual, that we are called to care for the suffering, and that — extrapolating from the above — poverty underlies much of the third world's miseries. In addition, implied for addressing all of these tasks is the setting up of powerful institutions — churches, schools, hospitals, and clinics.
It was these institutions of development that Illich was addressing, saying it was time for the church to withdraw from this sort of development so it could rediscover its “specific function,” he said, which was “the annunciation of the gospel.” This would be the church's “contribution to development which could not be made by any other institution.” In 1967, he was saying that other organizations could carry out these tasks.1
This call went unheeded. Instead, the Christian Medical Commission (CMC), founded in Europe in 1968, provided a Christian rationale for development in the form of primary health care; it was one of the main organizations influencing the articulation of primary health care as presented at Alma Ata in 1978.5 Several recent reviews have reaffirmed the role of the CMC in developing primary health care, along with the influence of Illich and others.6-9 However, these reviews do not reference Illich's call for the church to withdraw from development as noted above. Rather, they refer to his best-selling Medical Nemesis and his Tools for Conviviality, both of which challenged the assumption that more medical technology led to better health.
There certainly was synergy between Illich's views of medicine and the primary health care redirection advocated by the CMC. But Illich, even before Medical Nemesis, had made clear what this redirection would mean for the church: letting go of power, which, he said would be painful because “the church still has so much power — which has so often been used for evil.” He titled his presentation “The Powerless Church.”1
“It is my thesis,” he wrote,
… that only the church can ‘reveal’ to us the full meaning of development. To live up to this task the church must recognize that she is growing powerless to orient or produce development. The less efficient she is as a power the more effective she can be as a celebrant of the mystery. 1
Illich's thesis requires some unpacking. What seems particularly strange is his call to renounce power. Many would argue today that power is needed, both to announce the Gospel and to carry out development. Further, it seems anti-climactic as well as counter-intuitive, that Illich's radical proposal was what the Church had claimed its mission to be all along - the annunciation of the gospel. What, then, is the nature of this gospel, this mystery? What made Illich state the obvious as a radical proposal? And when he said “annunciation,” did he simply mean the tasks of preaching and teaching?
Most of us have a concept of what the gospel is and can capsulize it: Good News; or John 3:16; or salvation from sin by Christ's sacrifice; or the Incarnation and Atonement; or justification, sanctification, and glorification. Our review of medical missions, however, reveals that over the last two centuries, apologists have included a great deal which may not be gospel. In this context, we will begin considering what the gospel is primarily by suggesting what it is not.
• The gospel does not free us to gain secular power, but rather to relinquish and avoid it; consider Jesus’ arrest in Gethsemane. We may now recognize the power of our medical science, for example, and we can even advocate its judicious use. However, we cannot claim that the gospel is the power behind it, the way that Lowe claimed it was the power which made Britain the greatest nation in the world. Either claim would be blasphemy.
Today we are cannier. We don't attribute the benefits of our medical science or western civilization directly to the gospel. However, we see little conflict in employing them alongside the gospel as a means of demonstrating our compassion. Despite its value, we must remember that employing medical science requires complex institutions and power. Think of any hospital. Should the church be managing these complex and powerful institutions?
• The gospel does not admonish us to eliminate suffering, but rather to endure it and to suffer compassionately with those who are suffering. In identifying the Christian roots of contemporary humanitarianism, Dider Fassin writes,
[T]he valorization of suffering as the basic human experience is closely linked to the passion of Christ redeeming the original sin… The singular feature of Christianity in this respect is that it turns suffering into redemption.10
McNeill and his colleagues explain:
The mystery of God's love is not that he takes our pains away, but that he first wants to share them with us . . . The great mystery is not the cures, but the infinite compassion which is their source.11
Biblically we are enjoined to suffer with those who suffer (Rom 12:15), and to share in the sufferings of Christ (I Pet 4:13). We also, of course, follow Christ when we seek to comfort those who are suffering — but this is most authentic when rooted in our own experience of suffering, as it was with Christ. To seek only to eliminate suffering is to blunt the Biblical understanding of it.
But, some might ask, how should the church as an institution relate to human suffering? This question exposes the fundamental issue underneath Illich's critique of development. Development needs an institution to carry it out. The Gospel is not an institution. When we put it into a sociological or political structure or reduce it to an ideology or an “ism,” we have subverted it. Jacques Ellul was disturbed enough about this subversion that he wrote a whole book about it and, to reduce confusion, called the real Christianity “X.”12 Illich took the discussion one step further: “the subversions of what Ellul calls “X”… I would openly name, divine grace.”13
Please note that Illich and Ellul are not calling for a new ecclesiology. The call is to announce and live the Gospel despite the institutions of church and mission and development which are inevitable. They do not call us to destroy institutions. We may claim institutions facilitate living out the Gospel. Illich seems to suggest they more likely get in the way. I suspect Illich would have denied an institutional church could respond to the suffering of peoples. I suspect he would have said only people can respond to the suffering of people.
• Several of the sources above made the claim that as Christian doctors we are imitating Jesus’ healing ministry. We are not. Jesus healed by miracle; we treat by adjusting biological mechanisms. Jesus eliminated disability; we only manage it. Adjusting a disordered biological mechanism is good, but it is not a miracle. There is nothing in biomedical treatments that is distinctive to the gospel. There is also nothing wrong with adjusting mechanism, but that is not what Jesus did.
We do not heal. We treat and, in the process, require large and powerful institutions. Should the church be burdened with all this that biomedicine requires?
• Finally, living out the gospel does not involve recruiting members, as for a club, but loving all people unconditionally (Mat 11:28). Medical mission should be the same. Determining who is in and who is out is God's business, not ours.
However, for the efficient running of institutions such as churches or hospitals, membership becomes important. Who can work here? Sometimes that decision for mission hospitals is based on religious membership as much as on work ethic and skills. Yet, religion as a club distorts the gospel. The best way for the church to relieve the distortion is to withdraw from the work of managing these institutions.
The gospel does not require us to follow an agenda of wholistic development which may have been derived from thoroughly Christian principles. In fact, the gospel — that is, the mystery referred to repeatedly by St Paul and named here by Illich — may be impeded by people trying to carry out complex programs spawned by that same gospel. The power of the gospel, after all, is not the efficiency or success of the development program, but “Christ in you, the hope of glory” (Colossians 1:27). Let development continue, and let us who are technicians — doctors, teachers, agriculturalists — join those complex development structures wherever they are and seek as much as possible to redeem them. But, let the gospel be the gospel, the news which is good.
Listen to some of these hints from Illich about what the gospel is:
• The function of the church “is to recognize the presence of Christ among us through liturgical celebration and to charge human beings, through these celebrations, with the proper emotions toward social action… The less efficient the church is as a power, the more effective it is as a celebrant of the mystery.”14 The mystery of the gospel, we saw, was the presence of Christ in us — and (according to the Jerusalem Bible translation) “among” us. Institutional power, even unwittingly, can mask this presence of Christ.
• “What the church contributes through evangelization is like the laughter in a joke. Two hear the same story — but one gets the joke.”1 In the same way that embracing the gospel gives us ears to hear — in this case, ears to hear the meaning of the story and to respond by laughing — so the gospel can provide us with ears and eyes to hear the meaning of suffering and, correspondingly, the meaning of healing. An efficient powerful institution can never do this; only the gospel can.
• “The Christian wants to remain free to find through the gospel a dimension of effective surprise beyond and above the humanistic reason which motivated social action.”1 Humanistic reason can motivate social action in the same way scientific medicine can enable excellent medical care or management principles can build an efficient and powerful institution, even an institutional church. This is not the good news of the gospel, but the laughter, the surprise: these may be the Holy Spirit breaking through.
• The rejection of power, in Greek the anarchy, of Jesus troubles the world of power, because he totally submits to it without ever being part of it. Even his submission is one of love. This is a new kind of relationship, which Paul has well explained in Romans chapter 12.15
Romans 12:2 admonishes us not conform to the pattern of the world (NIV translation), and not to model ourselves on the behavior on the world around us (Jerusalem Bible). In other words, not to be part of the world of power. Earlier in the same article, Illich refers to:
… the analogy between the answer to the devil who tempted Him with power and to the Herodians who tempt Him with money. His response is clear: abandon all that which has been branded by Caesar; but then, enjoy the knowledge that everything, everything else is God's, and therefore is to be used by you… 15
Illich calls Jesus a “dropout from power and money,” and explains:
The established order of power is evil not because it is bad, but because it is a spiritual, demonic establishment in this world. The Kingdom of God is its opposite.15
Illich's critique was of institutions, not of living out the gospel. His simple plea 50 years ago was that we disengage from development institutions so that we could more fully live the gospel. It’s time to begin.