A History of Development of Medical Missions and Catholic Evangelization in Sub-Saharan Africa From the Early Twentieth Century to the Present: Tracing Some Representative Founders and Orders in the Context of the Twentieth Century Church

Abstract

Although the care of the sick has been a charism of Catholic community since the beginning, and hospitals as we know them have developed since the fourth century, religious orders began to develop hospitals as part of their mission work during the colonial expansion of the seventeenth century. These early efforts, however, were primarily a response to the needs of the colonists as well as recognition that the poor who were sick required care in these regions. It can be argued that medical missions developed during the twentieth century as a response to the outreach of Protestants as well as the exposure of physicians to the needs in mission territories, and that their advancement and success impacted the attitudes of the popes and bishops of the twentieth century. This article examines several individuals and organizations who have contributed to the development of medical missions in Africa in modern times and trace the approach of the Church toward medical missions by exploring missionary religious orders, especially women’s religious orders, and papal and council documents. It primarily considers the role of medical missions in areas that had only a limited Catholic presence prior to nineteenth and twentieth centuries, and where Catholic health care and the local Catholic Church essentially developed together, and considers ways in which the growth of medical missions and the thinking of the Church developed together.

Introduction

Some version of healing and healers exists in nearly every ancient and modern culture. Physicians as we know them coalesced in ancient Greece, where Hippocrates clarified what an honorable physician should do and avoid; even then the vulnerability of the sick was sometimes exploited for the personal benefit of those from whom they sought help. Aquilina, in The Healing Imperative, makes a strong case that medicine as we know it today is inextricable from the growth and ethos of Christianity. He goes so far as to say, “We have medicine because we’re Christian.” (Aquilina 2017, xiii) Although much of the history of the spread of Christianity is besmirched by foreign Christians arriving to exploit the local population and land rather than to serve the population, the ideal of medical missions is consistent with the command of Jesus to “heal the sick … and say to them ‘The kingdom of God has come near to you.’” (Luke 10:9) The Catholic Reformation coincided with worldwide exploration by the European powers and led to the spread of Catholicism and non-Catholic Christianity both by imposition and by proposition. Even those who were involved in coercing the population into “accepting” Christianity often recognized the need for genuine catechesis and witness. Fortunately, reform always led to the rise of religious orders initially filled with people seeking holiness and ways to serve Christ. In many cases, this involved schools and hospitals, and although women religious had to negotiate for serving outside the walls of their monasteries, women’s religious orders have been instrumental to the development of Catholic culture in many places during the twentieth century. In this article, we will explore the Tertiary Sisters of St. Francis (TSSF) in Cameroon, the Medical Mission Sisters (MMS), Maryknoll, and the Medical Missionaries of Mary (MMM) as representative contributors to this exciting story.

While religious in many cases can be trained to be nurses, it has proven difficult to achieve an adequate physician workforce from within the religious orders; thus, mission hospitals supplement their workforce with lay and even non-Christian missionary and local physicians. In some cases, this has been addressed by the development of lay physician missionaries; two approaches to this solution will be explored here: Mission Doctors Association and the Catholic Medical Missions Institute. The interplay between the physician leadership necessary in medicine and the usual authority structures of religious orders has led to complexities in the delivery of health care in Catholic institutions and dioceses, as has the dynamic of strong women authority figures in positions historically held by men (Wall 2015). Despite this, the need for physicians in hospitals has led to mission projects to increase the physician workforce while maintaining the Catholic or non-Catholic Christian identity of the institutions.

This article will examine several individuals and organizations who have contributed to the development of medical missions in Africa in modern times and trace the approach of the Church toward medical missions. Although in many cases, these missions also interact with government programs, the World Health Organization, and other international institutions such as the World Bank and the International Monetary Fund, it is beyond the scope of this article to consider these issues in detail. We are primarily considering the role of medical missions in areas that had only a limited Catholic presence prior to the nineteenth and twentieth centuries, and where Catholic health care and the local Catholic Church essentially developed together. There is much more literature on the impact of religious missions on health care than on the impact of these missions on the Church, but the growth of medical missions and the thinking of the Church seemed to interact in many ways. The second section of the discussion will examine papal documents that have specifically impacted medical missions and consider how the popes have advanced religious and lay contributions to Catholic health care and evangelization in this realm.

Background

Any discussion of “Africa” must be predicated by the reminder that “Africa is not a country.” From a western point of view, Africans are often considered a monolithic group of people, without even considering other words such as “culture” or “community.” In fact, Africa consists of 54 countries and thousands of people groups speaking hundreds of languages and dialects, with people group boundaries not equivalent to national borders, many of which were drawn and continue to be influenced by former colonial powers. The spread of Catholicism in Africa consists of two major time periods, the first being at the beginning of Christianity at the time of the great cities of Carthage and Alexandria; only a remnant remained after the rise of Islam in the latter half of the first millennium. The beginning of the second period of missionary expansion coincides with the Catholic Reformation and unfortunately with colonial exploitation and the ongoing African slave trade, although most missionaries opposed the slave trade and sought to replace it with other commerce (McGonigle and Quigley 1996, chap. 11). McGonigle and Quigley point out that “high quality” missionaries followed the colonists and that, “Because human development of the new African converts was an integral part of the preaching of the gospel, missionary compounds included schools, dispensaries, and hospitals as well as churches.”

The TSSF in Cameroon

The story of the TSSF in the Northwest Region of Cameroon will serve as a case study for the role of the Catholic mission hospital and how the advancement in thought of medical missions by the Vatican impacted options for missions. Cameroon was initially colonized by the Portuguese but in 1884 became a German colony. The French portion was added by treaty in 1911. It was invaded by the British in 1914 and divided between the British and the French in 1919. After independence, the British colony was rejoined to the French Cameroon (van der Kamp 2017, 44); the current political conflict is based in this controversial union. Overall 32% of Cameroon is recognized as Catholic, about half of the Christian population. Cameroon was evangelized beginning in 1890 by the German Pallottine Missionaries from Limburg, Germany (Bamenda Archdiocese n.d.). The Mill Hill Fathers arrived in the region of Bamenda from England in 1922 to replace the German missionaries who were required to leave the area. Although the “care of the sick” was part of the charism of the Mill Hill Fathers, at that time canon law prohibited priests and members of religious institutes from practicing medicine.

In 1935 at the invitation of the Mill Hill Fathers five sisters from the TSSF in South Tyrol, Italy, arrived in Kumbo to assist in setting up a maternity hospital. Founded in Brixen by Venerable Sr. Maria Hueber in 1701, it is not clear from the English language information available how these sisters were connected to the Mill Hill Fathers or to health care, as they were founded to provide education to girls. The institution was incorporated as a hospital by the Cameroon Government (at the time under the indirect control of the British) in 1952. St. Elizabeth’s Catholic General Hospital is now a large well-respected facility with 350 beds and approximately 400 workers (van der Kamp 2017, 77-78) as of 2013—the current political conflict has severely limited the functioning of the hospital. St. Elizabeth’s maintains the only Cardiac Surgical Center in Central Africa. This was completed in 2009 in partnership with Fondazione Bambini Cardiopatici del Mondo (Giamberti et al. 2018). In 1953, the sisters responded to a request to found a maternity ward and dispensary in Njinikom, Northwest Region, Cameroon, which is now the 250-bed St. Martin de Porres Catholic Mission Hospital. The Rehabilitation Center St. Joseph’s Children and Adult Home in Bafut was established in 1976 (SAJOCAH n.d.). In all of these regions, the Sisters operate schools as well as their hospitals and clinics. Shisong is also served by the Order of Friars Minor Capuchins who arrived in Bamenda in 1988 (Bamenda Archdiocese n.d.). Both the TSSF and the OFM Capuchins in Cameroon, while originally established by religious sisters and brothers from Italy, are now almost entirely Cameroonian. Although a few elderly sisters from Europe remain, the postulants, novices, and leadership of over 200 sisters are Cameroonian (or other Africans), including two physicians and two in medical school. In these towns, large, vibrant, well-attended parishes with active lay apostolates and religious ministries represent Catholic communities and culture. ¹

Medicine in Catholic Missions: Dr. Anna Dengel

The transition from “care for the sick” to high level medical care in Catholic mission and evangelization, particularly among women religious, owes much to the work and advocacy of Dr. Anna Dengel. Prior to 1936, sisters were forbidden from the practice of medicine and surgery, and even priests were severely restricted in this area. Various explanations are offered. Although some sources claim that this was out of concern that exposure to bodies and childbirth would breach the vow of chastity of the nuns (Wall 2015, 13), restrictions on the practice of medicine by clerics date back to the twelfth century. Concerns included it being “worldly,” that it would require violating the residency obligations of monks, concerns about “cutting or burning,” and worries about incurring an irregularity in case of an error or bad outcome (Fanning 1911). Dr. Dengel and others including bishops committed to missions petitioned Pope Pius XI to change this (Wall 2015, 13), of which the history of the Mill Hill Missionaries says “The care of the sick was a special problem. Current Canon Law forbade priests and religious to engage in medical work other than simple nursing … Generally, the Asian and African mind sees on (sic) essential connection between the holy man and the healer. To be effective the missionary had to be some sort of healer. The reforms achieved by Anna Dengel’s group in the 1930s changed all this. It gave the kickstart to an expansion of medical work in Catholic missions throughout the world” (Mill Hill Missionaries n.d.).

Anna Dengel was born in Austria and developed a heart for missions early in her life; after learning that women in India were suffering for not being attended by male doctors, she sought medical training and residency in Cork, Ireland and Clay Cross, England, respectively. Her work in India convinced her that women professionals were desperately needed in the missions, and she dedicated her life to making this possible. She realized that seeking money in America was likely the path to success, and she went there with the full support of her backers in England, Austria, and India. As she was unable to join a professed order, she was persuaded to form a “Pious Organization.” Four founding women medical professionals, forsaking religious vows for the responsibility of medical care of the sick, became the Society of Catholic Medical Missionaries, now the MMS. This order began its work in the Punjab in India, where Dr. Dengel had gone for her initial mission assignment and learned of the tremendous need of the women for medical care by women, as well as the ongoing need for the love of Christ being offered by the Franciscan Missionaries of Mary. The plans to expand to Africa were disrupted by World War II, and the order did not begin work in Ghana until 1947. The magazine The Medical Missionary started by the MMS and Dr. Dengel filled a gap as being the first periodical on Catholic medical missions in any language that she could access at the time. She used this platform to educate supporters and advance the cause of Catholic medical missions around the world. It was not until after the Vatican publication of Constans ac Sedula in 1936 that the MMS became an order of nuns in 1941 (Winter 2016, chap. 23). ²

Even at the time of the development of these orders, there was not agreement on whether the primary purpose of medical missions was to promote conversions or simply to alleviate human suffering through western medicine. In a letter to Anna Dengel supporting her work Cardinal Van Rossum of the Netherlands wrote, “this is the moment to extend as largely as possible the medical contribution to missionary work … but also for the conversion of the pagan world … how necessary is your contribution to the great work of extending the Reign of Christ on earth.” (Winter 2016, chap. 13) For Anna, the purpose was to “alleviate human suffering in the defenseless and underserved … and thereby witness to the universal compassion of a loving God.” Completely committed to the authority of the Church, the MMS resolved to integrate these ends. In both Protestant and Catholic mission circles, disagreement over this balance is a major reason for the large number of mission organizations and lack of inter-agency collaboration. From a historical perspective, the role of missions in imperialist expansion by European (white) countries contributes to the reluctance of some missionaries, and the resistance of some receiving cultures, to permit what they see as proselytizing.

Other Developments and Religious Organizations

Other organizations that have made important contributions to Catholic medical missions in sub-Saharan Africa include the MMM, the Maryknoll Sisters, the Missionary Sisters of the Holy Rosary, and Sisters of the Immaculate Heart of Mary, Mother of Christ (Wall 2015, 24-28), and the Catholic Medical Mission Board (CMMB n.d.a, b). The MMM were founded in Nigeria by Marie Martin who recognized the value of good nursing and medicine as a nurse during World War I. She also began her missionary service as a lay midwife, discerning a call to religious life in 1921 but unable to reconcile her calling with the prohibition of the practice of medicine for women religious. In the meantime, various illnesses and injuries delayed her moving forward; at the end of a retreat in February 1936, she received the news that the Sacred Congregation of Propaganda Fide would now desire medical work by Catholic Missionaries. Permission to found the MMM congregation was received from Rome in May. They were persuaded to found the community in Nigeria by His Excellency Archbishop Antonio Riberi, the Apostolic Delegate to East and West Africa, who had experienced for himself the urgent need for medical missionaries. They began their work in Anua, Nigeria, where they immediately included African-born women in their congregation and spread throughout Nigeria and Africa as well as around the globe. In her book, Into Africa, Barbara Mann Wall reviews the role of the MMM, and the contributions of both Irish and Nigerian sisters, during the civil war in Nigeria between 1967 and 1970, demonstrating the heroic contribution of religious missions when civil society is not available (Wall 2015, 100-112). ³

The Foreign Mission Sisters of St. Dominic, known as the Maryknoll Sisters, were founded in 1912, and approved as a religious congregation in 1920. The founder of this first American-based women’s religious congregation for overseas missions, Sister Mary Joseph Rogers, was inspired by the Protestant missionary work (CMMB n.d.a, b). Their work in Africa began in 1948. Although health care is not the purpose of the Maryknolls, their size and diversity (Fathers and Brothers, Sisters, Laity, and Associates) have led them to have an impact in this area. Maryknoll was founded in an intertwining way with the CMMB, which was also founded in 1912, by Dr. Paluel Joseph Flagg, an anesthesiology resident moved by the great need of the leprosy patients in Haiti (CMMB n.d.a, b). Although they sent an early medical missionary to China, Dr. Margaret Lamont and her family, their work is primarily in the support of missions via donation of medications and supplies, and short-term missionary support. The CMMB and Maryknoll were instrumental in supporting the early fundraising of Dr. Dengel, as was the hard work of Dr. Dengel important to the early fundraising of the CMMB (Winter 2016, chap. 7).

The Laity in Medical Missions

In 1948, Monsignor Anthony Brouwers was appointed the Director of the Society for the Propagation of the Faith for the Archdiocese of Los Angeles (Dellinger 2004, chap. 5). ⁴ In that position in 1954, he traveled to Nigeria to attend the all-Nigeria Marian Congress and remained afterward to make a 90-day tour of the missions. On this tour, he observed that 26 thousand local and foreign priests were ministering to 27 million Catholics in the third world, in addition to being responsible for the evangelization of the billions of other people composing that population. He noted that much of their effort was devoted to secular, not religious work, and concluded that the best solution was to send lay people to help. He noted that in comparison to Protestant mission work, only about 7% of Christian missionaries sent from the United States were Catholic. He also noted that “hundreds of so-called hospitals (were) staffed by only nurses and paramedical professionals. There was not a single physician at these stations …” He said, “I returned to Los Angeles in early 1955 resolved to do what one could to recruit, train and assign lay men and women for short terms as volunteer helpers to missionary bishops.” He founded Lay Mission Helpers in 1955 and Mission Doctors Association in 1959; these are the oldest Catholic lay sending organizations in the United States, canonically defined as pious associations. Forming and sending lay people as missionaries was not universally supported, however, and was opposed by the National Director of the Society for the Propagation of the Faith, the powerful Archbishop Fulton Sheen. Today, the role of Catholic laity in missions remains uncertain; one wonders how this might have been different had Monsignor Brouwers not died at the young age of 51. Nevertheless, Mission Doctors Association has sent more than thirty Catholic physicians and dentists along with their families to serve in mission hospitals and clinics in Africa and other mission sites. Monsignor Brouwers emphasized that “The first objective of the Lay Mission Helpers ever must be their own spiritual perfection and growth in holiness. Without this, all other objectives and labors in missionary fields shall be of little or no value before God and Holy Church.” Although the number of lay Catholics serving in overseas missions remains small, their witness is significant, calling those around them to increased giving and prayer, and to find other ways to give of themselves and pursue holiness. Additionally, although the overall role of foreigners in any mission field is sometimes criticized, the local partners of these lay missionaries are also inspired and encouraged, being well aware of the challenges associated with secular individuals serving in a foreign country.

Around the same time as Dr. Dengel was forming her religious order, and the CMMB was founded, Monsignor Christopher Becker founded the Catholic Medical Mission Institute in Würzburg, Germany (Winter 2016, chap. 5). The founding purpose of this apostolate was to train lay men and women as physicians for foreign missions. Their mission is to interface between health service, Church development cooperation, work for international justice and the missionary presence of Churches in the different cultures (Medical Mission Institute Würzburg n.d.). While Dr. Dengel was committed to a community of religious and working toward the possibility of her sisters taking public vows, she was supportive of this lay organization rising up to advance the medical missions movement and making Catholic health care available as the Protestants were doing. The Catholic Medical Mission Institute began training healthcare professionals in 1922, and in 1925, eleven male and three female doctors took their missionary oaths for ten years of overseas missionary duty. This institute has owned and assisted diocesan-owned hospitals in several countries in Africa and Asia.

Papal Documents and Action on the Missions

Much of the above work was done in the context of a new and evolving focus of the popes on missions. The Sacred Congregation Propaganda Fide was inaugurated in 1622 after the Council of Trent by Gregory XV, to try to dissociate the spread of Christianity from colonialism (McGonigle and Quigley 1996, chap. 5). The next 300 years saw growth in missions by both Catholics and Protestants, religious and lay, and a movement toward greater ownership of “Church” by the indigenous peoples. After World War I, a revised approach was again needed to separate the Church from the states and colonialism which had crept back into the governance of the Church. Pope Benedict XV issued an apostolic letter Maximum Illud, On the Propagation of the Faith Throughout the World in 1919. This letter does not specifically address medicine or health care, but it indicates that “Proficiency in all Branches of Learning” is desirable, emphasizing “… sacred and profane subjects, anything they might need in the missions.” (Benedict XV 1919, 23) In honor of the centennial anniversary of this document, Pope Francis for a special “missionary month” in October 2019 (Wooden 2018).

Popes Pius XI and Pius XII, while dealing with the horrors and complexities of the rise of Nazi Germany and communist Russia, and subsequently World War II, were also attentive to the missions and the urgent need for ongoing evangelization. In 1925, Pope Pius XI, who became known as the “Pope of the missions,” hosted the Missionary Exhibition in Rome during the Holy Year. This exhibition in the Vatican Gardens received contributions of art and artifacts from missionaries throughout the world, and it has become the Ethnological Museum (Vatican Museums n.d.). He gave its purpose as being “to give the pilgrims an object lesson in what is being done, and a silent exhortation as to what they should do, to promote the preaching of the Gospel to the heathen” (Laux 1945, sect. 3, chap. IV). Pius XI followed this up in 1926 with his encyclical Rerum Ecclesiae, On Catholic Missions. While much could be said of this letter, key points include moving the Society of the Propagation of the Faith to Rome, affirming the need to increase the native clergy in mission cultures, and the importance of health care to the witness of Christ (Pius XI 1926, 14, 19, 30). Prior to this, he had written an encyclical invoking St. Francis de Sales encouraging the bishops to remember the call to holiness and apostolate of the laity (Pius XI 1923). In 1936, in the annual Acta Apostolicae Sedis, he included Constans ac Sedula, not only permitting but emphasizing the importance of members of religious orders carrying out the full range of surgical and obstetrical care when appropriate (Pius XI 1936). This was a crucial change for the MMS and the future of other orders including the TSSF; in addition to allowing sisters to be physicians, it allowed the sisters who were nurses to better participate in the care of patients.

On the 25th anniversary of Rerum Ecclesiae, Pope Pius XII promulgated Evangelii Praecones, On Promotion of Catholic Missions. Here, he celebrates the progress of the goals set forth by his predecessor, particularly in advancing native clergy and naming bishops native to the mission regions. He again emphasizes the importance of the admonition of Jesus to “… heal the sick that are therein and say to them: the Kingdom of God is come nigh unto you.” He enthusiastically supports the role of religious, including nuns, undertaking medical training but also says, “With regard to medicine and surgery, however, it will certainly be advisable to enlist the services also of laymen, provided not only that they have taken the necessary degrees for this work, and are willing to leave their homeland in order to help the missionaries, but also that in the matter of faith and morals they leave nothing to be desired.” (Pius XII 1951, 47-48) Responding to conflict and independence movements in Africa, Pope Pius XII followed this in 1957 with Fidei Donum, On the Present Condition of the Catholic Missions, Especially in Africa. He emphasized the importance of missions in Africa and indigenous clergy, and the careful training of a “Catholic elite” prepared to participate in social and political leadership (Pius XII 1957, 26).

St. John XXIII promulgated Princeps Pastorum, On the Missions, Native Clergy, and Lay Participation, in 1959. Observing the fortieth anniversary of Maximum Illud, the key points of this encyclical are in its title; the reference to the laity is largely in the local laity. While acknowledging the ongoing need for foreign missions and the role of social welfare projects, he offers caution not to “clutter and obstruct the apostolic work of the missions with an excessive quantity of secular projects” (John XXIII 1959, 22).

The Vatican II Council has had a major impact on missions from several directions, and the impacts are still under evaluation as the implementation of Vatican II is ongoing. Several documents have had an impact on medical missions. Gaudium et Spes, Dignitatis Humanae, and Ad Gentes led those involved in missions to revisit the purpose and methods in a comprehensive way, and Lumen Gentium and Perfectae Caritatis led to changes in the functioning of religious orders (Wall 2015, 18). To some extent, it has led to even greater resistance on the part of some to sharing Christ with the world, as the perception that souls might be at risk is less vivid, and some scholars even argue that Ad Gentes reverses the direction of the Fidei Donum in its emphasis on evangelization (Wall 2015, 19). Numerous papal documents following Vatican II continue to explore these issues, including Populorum Progressio and Africae Terrarum in 1967, Evangelii Nuntiandi in 1975, from Pope Paul VI, Redemptoris Missio in 1990 from St. John Paul II, and the US bishops document “To the Ends of the Earth” are some examples (Frazier 2010).

Conclusion

Although the care of the sick has been a charism of Catholic community since the beginning, and hospitals as we know them have developed since the fourth century, religious orders began to develop hospitals as part of their mission work during the colonial expansion of the seventeenth century. These early efforts, however, were primarily a response to the needs of the colonists as well as recognition that the poor who were sick required care in these regions. It can be argued that medical missions developed during the twentieth century as a response to the outreach of Protestants as well as the exposure of physicians to the needs in mission territories, and that their advancement and success impacted the attitudes of the popes and bishops of the twentieth century. The role of missions in modern times and the ends of Catholic health care continue to be explored by the missionaries and by the magisterium of the Church. Certainly, both health care fitting the dignity of the human person and sharing of the good news of Jesus Christ remain necessary in the twenty-first century. In the present, there is much more opportunity for missions and sharing of successes and failures from Africa to the rest of the world as well as from North America and Europe to Africa, and much work necessary within all of these regions. In Fratelli Tutti, Pope Francis proposes:

Once more we are being reminded that “each new generation must take up the struggles and attainments of past generations, while setting its sights even higher. This is the path. Goodness, together with love, justice and solidarity, are not achieved once and for all; they have to be realized each day. It is not possible to settle for what was achieved in the past and complacently enjoy it, as if we could somehow disregard the fact that many of our brothers and sisters still endure situations that cry out for our attention.” (Francis 2020, 11)

Author Biography

Ellen M. Dailor, MD is a cardiac anesthesiologist and medical missionary. She has worked in academic and community care in the United States and served overseas short and medium term contributing both general and cardiac clinical anesthesia as well as teaching with organizations including Mission Doctors Association, Helping Hands Medical Missions, the American Society of Anesthesiologists, and the Canadian Anesthesiologists’ Society International Education Foundation. She serves as a volunteer for the American Board of Anesthesiology. Other clinical interests include quality improvement, patient safety, and physician wellness, while related mission interests include ecumenical dialogue, evangelization, and theology.

ORCID iD

Ellen M. Dailor https://orcid.org/0000-0002-2919-0683