COMMENTARY
Danielle Ellisa
a MTS, MD(c), University of North Carolina Chapel Hill School of Medicine, and Theology, Medicine, and Culture Initiative, Duke Divinity School, Durham NC, USA
Missions have been a part of the Christian faith since its genesis. Various approaches to transmitting the faith through missions have been implemented over time, some with unforeseen and frankly negative, long-term political, social, and even theological consequences. In medical missions, specifically, the consequences include the potential of compromised individual and collective health. These vulnerabilities make it essential to consider the theoretical and practical approaches with which we, as Christians, engage with our neighbors.
Missiologists critically and theologically consider the motives, methods, and mandates of the Christian believer in the world. Efforts to reconfigure the role of missions from a past intertwined with imperialism to one that brings each party into partnership are ongoing. In medical missions, questions about how to assume a Christian posture are complicated, not only by the sociohistorical context of the missions movement but also by the fact that medicine in and of itself engenders imbalances in power.
This paper puts forth a proposal for a posture in medical missions as understood through the lens of Philippians. In the context of Paul’s mission to this group of early believers, the apostle repeatedly encourages his congregation to imitate Christ. In his letter to the Philippians, he lays out what Christ did and how his followers might hope to be like him. Paul describes Jesus’ wholly countercultural disposition and actions, giving his audience the opportunity to consider how this might inform their own lives. In so doing, he also provides a framework for understanding the ideal missionary. What follows is a Pauline construal of the call to imitation as a disciple, a discussion of how those engaging in medical missions might embody the same posture as the incarnate Christ, and a reflection on how a shift in posture might facilitate greater participation for both disciples and disciplers in God’s restoring work on earth.
Key words: humility; medical missions; imitation
The sense that bearing witness to the character of Jesus is essential to the Christian faith has been present among believers throughout history, likely generated by the “missional” spirit that pervades the New Testament in all of its “sending” language.1 That said, “missions” qua evangelism (i.e., institutionalized missions targeting primarily overseas populations) dates only back to the sixteenth century, introduced by Jesuit Christians to refer to the conversion of distant pagan territories, particularly colonial territories.2
This conceptualization of missions developed largely from the theological conviction that the incarnation of Jesus requires the gospel to be transmitted and received “under the same conditions that we receive other communication” (i.e., verbally) and the interpretation of Matthew 28:19 or “The Great Commission” as a mandate specifically for overseas missions.3 The emphasis on evangelism was so strong that during the seventeenth and eighteenth centuries, when medical missions in the modern sense began to take hold, medical missionaries were often encouraged to practice medicine only as an “occasional occupation”, and leadership within missions organizations questioned whether medical knowledge actually lost rather than gained influence among native populations as “European medicine… was not at all efficacious in the colonies.”4 Medical missons, as performed in this era, have engendered a sense of mistrust, not only among local people but also among the emerging secular global health community. This sentiment is best exemplified in this excerpt from a study executed by an academic institution investigating so-called, faith-based health providers (FBHP) in Sub-Saharan Africa:
[Faith-based organizations] have been neglected by the worlds of research and policy for decades, mainly as a result of a general refocusing on public health provision and also since the historical (and sometimes present) drivers of faith-based health provision have been treated with mistrust, especially in connection with the controversies around health care provided with the underlying intent to proselytize… the slowly emerging evidence on FBHPs suggests that they are not simply a health systems relic of a bygone missionary era, but still have relevance and a part to play (especially in fragile health systems), even if we still know little about exactly how they function.5
At the risk of suggesting that historical approaches have been exclusively harmful, one must acknowledge the role of colonial-era missions and medical missions in transmitting the Christian faith and caring for the health of the world’s people.1 Nevertheless, given the actual and potential dangers of missions and medical missions, it is essential to consider the theoretical and practical approaches with which we as Christians engage with our neighbors. The term “missionary”, meaning “the one sent” (Gk. apostolos), is found in the New Testament 79 times. Thus, in considering a posture for medical missions, I turn to the quintessential apostle, Paul. What follows is a Pauline construal of the call to imitation as a disciple and a reflection on how those engaging in medical missions might embody the same posture as the incarnate Christ, facilitating greater participation for both disciples and disciplers in God’s restoring work on earth.
Paul’s letter to the church at Philippi is one of his most unusual and yet, arguably, most impactful. Paul begins this letter with an introduction that calls readers to imitate Christ’s humility:
1 Therefore if you have any encouragement from being united with Christ, if any comfort from his love, if any common sharing in the Spirit, if any tenderness and compassion, 2 then make my joy complete by being like-minded, having the same love, being one in spirit and of one mind. 3 Do nothing out of selfish ambition or vain conceit. Rather, in humility value others above yourselves, 4 not looking to your own interests but each of you to the interests of the others. (Phil 2:1–4, NIV)
Paul’s appeal in vv. 3–4 to adopt a Christ-like posture of humility is expounded upon in vv. 5–11. Specifically of Phil 2:5–11, commentator Samuel Bockmuehl notes that “the Christological argument [here] provides the spiritual focus, assurance, and incentive for the letter’s various instructions.”6 The theology Paul espouses in these seven verses unpacks not only some of the most foundational truths about Christ, but also a Pauline vision of what those truths mean for how followers of Christ might live as disciples, as disciplers, and for those called as practitioners of medicine.
Paul’s exhortation to the Philippians in Phil 2:5 frames the rest of this text. The command in the NIV reads “In your relationships with one another, have the same mindset as Christ Jesus.” Here, Paul calls his readers to imitate Christ, as he does in a number of his epistles (cf. 2 Cor 8:9; Rom 15:1–3; 1 Thess 1:6).7 Gordon Fee, a New Testament scholar, observes that “for Paul, ‘imitation’ does not ordinarily mean, ‘do as I did,’ but rather ‘be as I am.’”8 The qualifier “in your relationships with one another” suggests that Paul’s subsequent elaboration of Christ’s behavior, that which garners the command of imitation, can be understood to inform not only our mindsets, but also our relationality. From this launching point, we can proceed with an assessment of the doings and ways of being of Jesus that, for Paul, we should embody.
Jesus’ actions in the following verses—presumably, the ones which should serve as the foundation for the believer’s mindset—are two-fold: he “made himself nothing by taking the nature of a servant” and “humbled himself by becoming obedient to death” (Phil 2:7–8, NIV). Let us begin with the first of Jesus’ actions: “[making] himself nothing” (Phil 2:7). The Greek word that translates to “made himself nothing” (kenosis) suggests “self-emptying.”9 Paul’s other uses of the word “kenosis” refer to the idea of “rendering useless” (cf. Rom 4:14; 1 Cor 1:17, 9:15), so Paul is likely suggesting a nullification of privileges that Jesus might have rightfully claimed.10 Later, we learn the nature of Jesus’ self-emptying: “… being in very nature God, did not consider equality with God something to be used to his own advantage. Rather, he made himself nothing by taking the form of a servant” (Phil 2:6–7). So, then, we might conceptualize Jesus’ first action not as being stripped of his divine rights, but as a rendering useless of them—a decision to not count them as something to be used to his advantage. In his being made like humans, he assumes a posture of servanthood and susceptibility rather than one of superiority. Because Jesus’ divinity and humanity coexist in hypostatic union, his kenosis does not change who he is, but rather speaks to a voluntary change in status. In so doing, he subverts the earthly narrative of the likeness of men (as that which takes advantage of rights) and instead begins to write a new one, wherein to be made like man is to render any claim to rights as void and take on an essence of submission and insufficiency.
Next, Paul says of Christ that he “humbled himself and became obedient to death.” The Greek word meaning to “humble oneself” (tapeinoō) means to assign a lower rank or place to.11 This action reflects Christ’s taking the form of a servant and effectively adopting a position of low rank rather than one of honor. Moreover, we see that his self-humbling also entails a disposition of obedience.
But just how is self-emptying distinct from self-humbling, particularly since the words appear in adjacent clauses and may appear to suggest similar actions? Theologically, the two flow from Christ’s two natures: he empties himself as a function of being found in the form of God and humbles himself as a function of being found in the form of a servant. In effect, as God, he divested himself of a claim to privilege; as man, he humbled himself; and in both of these, he acted deliberately. Practically, one concerns an internal change in posture and the other a way of relating to others externally.
Paul, arguably one of the greatest missionaries in history, effectively grounded his approach in the imitation of Christ. Paul, like Jesus, adopted a disposition of obedience from the moment of God’s revelation to him on the road to Damascus. He deliberately lowered himself to the rank of those with whom he sought to share his life. It is this example that Paul calls the church at Philippi and, ultimately, all followers of Christ to imitate in Philippians 2:5–11.
Paul’s distinction between that which Christ did while in the form of a servant and likeness of man and what he did while in the form of God is not to promote a Nestorian Christology (i.e., to suggest that Jesus acted in one way as God and another as human), but to affirm two components of imitation. The first, not divesting himself of rights, but divesting himself of claim to those rights and voluntarily embodying a servant’s posture; the second, humbling himself or accepting a lower rank in obedience. The first, an internal change in posture; the second, informing a pattern of relationship. Each is valuable in informing a Christlike mindset, but a distortion of missions that under-emphasizes one or the other is problematic.
Missiologist David Bosch notes the significance of kenosis in missions: “the affliction missionaries endure is ultimately bound up in their mission.”12 In a discussion of four cardinal missionary motifs in scripture, Bosch highlights martyria—suffering. Missions, in light of Jesus’ mission of self-emptying, is not a triumphalist enterprise but rather inherently done in weakness.2 Related to this weakness is an acknowledgement that missions is not what the missionary, having taken the form of a servant as Jesus did, can do, but what God does to and through the servant. An underappreciation of the weakness engendered by kenosis can lead to an overly triumphalistic view of missions that overemphasizes the role of human work in the mission’s “success”. One consequence of relying so heavily on human effort in missions is the propagation of the savior complex. This phenomenon, codified in 2012 by Teju Cole, refers to the way in which distorted narratives that situate particular countries and peoples “as places in need of heroism… perpetuate the need for external forces to come in and save the day… [and reward people for] ‘saving’ those less fortunate.”13,14 Bosch writes:
Perhaps this [dependence on their own work] is, in part, what lies behind the tendency—particularly in Protestant circles—to interpret the Matthean version of the Great Commission (Matt. 28:18–20) primarily as a command and, with that, to overemphasize the autxiliary verb “go” (Greek: poreuthentes). As I have argued elsewhere, this is based on a faulty exegesis… It is also, however, the product of a deficient theology: in semi-Pelagian manner, we tend to prioritize human intervention and relegate the power of God to secondary status.12 (p.185)
The idea of self-emptying suggests something of which to be emptied, something to which one can no longer lay claim. For Jesus, that is equality with God; for a missionary coming from an imperial or high-income country, that might be something like the social, financial, and cultural capital conferred by their political membership. Christ’s kenosis, his rendering void his claim to divine rights and assuming a posture of servanthood, reminds missionaries emulating him that it is in weakness, insufficiency, and dependence on God, not triumphalist self-reliance we ought be sent.
Moreover, it should serve as a reminder, particularly for those coming with capital, that the way by which one enters the kenotic weakness of Christ does not mean changing one’s identity, but divesting oneself of a claim to the rights associated with the identity. To divest oneself of claim to those rights is not merely a matter of “going overseas”, but a function of the posture one assumes. This posture is informed by the second of Christ’s actions, humility, which is of equal importance in shaping a faithful Christlike mindset in missions.
The way in which Christ humbles himself by assigning himself a lower rank might be understood to inform a missions mindset externally: it sheds light on how he related to those to whom he was called. Douglas Campbell notes that Paul’s journey as a church planter is similarly characterized by having humbled himself in obedience. Firstly, Paul was willing to go the distance, not only geographically, but also socially.* Secondly, Paul was willing to set aside his “capital”. A well-educated Roman citizen, Paul had access to more social and economic capital than many of the people to whom he sought to preach the gospel. And yet, he leaves evidence in his letters that he set aside that capital, assigning himself a lower rank—humbling himself, we might say. In his ministry at Thessalonica, for example, Paul became a day laborer because the Thessalonians were.† Campbell notes the significance of “Paul [arriving] in Thessalonica looking like the people he was hoping to befriend and convert. He adopted the persona of a handworker and worked alongside the humble Thessalonians… He abandoned his cultural capital, lowering himself to the place where the Thessalonians lived, and became like one of them, so they could become like him.”15
Bosch notes that any religion that “claims universal validity” and is “inherently missionary” is at risk for paternalism; in Christian missions, he says, paternalism is an occupational hazard.12 In a model of missions that underappreciates Christ’s deliberate humility, relating to local peoples paternalistically is all too easy. Campbell describes the dangers of this posture in missions:
. . . missionaries arriving with a lot of capital are tempted to view their potential friends as people in need… The result is a patron-client relationship and is not a relationship of equality and of authentic friendship. A patron who frames a friend in terms of need risks [is] imposing a set of deficiencies on that person from outside… 15
The consequences of such missions are devastating:
. . . converts [were] framed in terms of need and were victimized and infantilized. Missionaries were framed in terms of provision and identified with European mores—often described as quintessentially white values. Authentic relationships were distorted and difficult.15
Thus, even when paternalism is not the intended mode of relationality between missionaries and local people groups, the sociohistorical contexts—colonialism, historically, and capitalism, more contemporarily—in which missions have been practiced may engender such dynamics. Efforts at partnership like the kind demonstrated by Christ and emulated by Paul demand an intentional and even unnatural subversion of the dynamics at play. To assign oneself a lower rank is indeed not often “natural” but the sort of humility to which we are called.
To understand how a model of missions informed by an internal kenotic disposition and a pattern of relationship grounded in self-humbling maps onto medical missions, requires an acknowledgement of the ways the practice of medicine is distinct from that of missions. Firstly, medicine is a service with its own telos: improving the health of those in one’s charge. Although medical missionaries in the modern era (i.e., the sixteenth century onwards) were concerned primarily with evangelism, faith-based organizations delivering medical care in low- and middle-income countries began to see the provision of healthcare as a good in its own right around World War I.4 The end of medicine is, therefore, set apart from the end of missions proper, and thus negotiating the joining of the two in the practice of medical missions is challenging. Secondly, even outside of the social, cultural, and historical factors that have contributed to economic and political inequity between regions of the world, medicine engenders its own power imbalances between patient and physician.
That in mind, the Pauline vision of missions speaks to a vision of medical missions nonetheless. Christ’s kenosis informs the missionary’s inward rendering void claim to his privileges and assumption of a servant’s disposition. Medical missionaries, in the same way, might embrace the weakness that kenosis engenders, avoiding the triumphalism and self-reliance towards which medicine tempts practitioners. This temptation is true of medicine anywhere, but perhaps even more so in settings with great need (i.e., where great strides are “easy” to make). Similarly, just as God is the author and perfector of salvation, He is the great healer. A kenotic disposition reminds medical missionaries that the physician, embodying the posture of a servant, is merely an intermediary of God’s work. Finally, it should remind medical missionaries coming from settings with substantial medical resources that although they need not divest themselves of those rights and privileges (in fact, it is advantangeous for them to make use of those while practicing medicine in settings with unmet need), they should not allow the privilege conferred by those settings to impede their capacity to embrace weakness and vulnerability.
Christ’s humility, as in the case of missions broadly, should inform the way medical missionaries relate to local persons and organizations. In relating to patients, especially considering that the physican-patient relationship is inherently unequal, this kind of humility is particularly salient. In relating to local practitioners and healthcare systems, a Pauline model of missions would move medical missionaries to assign themselves a lower rank, to work with intention against the paternalism that differences in resources, training, and the like might naturally engender. To begin, this would mean taking the time to learn the local system and its stakeholders. After all, it would be challenging to humble onself without knowing practically what that meant in the missionary’s specific context. The time required to inculcate deep understanding of a system, culture, and its people is significant and would likely require that medical missionaries conduct either long-term continuous or long-term intermittent trips rather than short-term ones.
Moreover, relationships between medical missionaries and local organizations (both governmental and non-governmental) would take the form of partnerships. In a partnership, medical missionaries would shift from technocratic, self-generated projects and solutions towards asking local practitioners what their needs are and how missionaries can be most useful in strengthening their capacity to address those needs. Practically speaking, that may include investing in training programs, cultivating a culture of quality improvement, and building up not only individuals but whole systems.
As the missionary par excellence, Christ provides the ultimate model for a faithful posture and pattern of relationship. In Philippians 2, Paul calls believers to imitate Christ, rendering void claims on the rights and privileges they hold and humbling themselves in obedience. To imitate Christ as a medical missionary, then, does not so much have implications on the delivery of care as it does on the posture from which one operates and the way one relates to one’s surrounding community. To be a disciple, a discipler, or a practitioner of medicine with the posture Paul calls us to imitate is one and the same—a call, like Jesus himself, to deliberately take on the posture of servanthood and humble ourselves, coming alongside those we serve as healers and as followers of Christ.
* Consider that the most prominent and likely initial convert in the city of Paphos was Quintus Sergius Paulus, a wealthy aristocrat. By contrast, the church in Philippi grew and flourished following Paul’s connection with a God-worshipping artisan named Lydia.
† Paul writes “because we loved you so much, we were delighted to share with you not only the gospel of God but our lives as well. Surely you remember, brothers and sisters, our toil and hardship; we worked night and day in order not to be a burden to anyone while we preached the gospel of God to you” (1 Thes 2:8–9). Paul recognizes his imitation of them as a launching point for them imitating him in return, and by the transitive property, imitating Christ (“I plead with you, brothers and sisters, become like me, for I became like you.” Gal 4:12).