Protestant Medical Missions in Iran: Negotiating Religion and Modernity in Mission Hospitals

Abstract

Focusing on the Protestant mission hospitals in Iran during the reign of Reza Pahlavi, this article analyzes the concepts and ideas referred to as medical care in missionary narratives as well as reactions of the Iranians to the missionary medical initiatives. Trying to situate mission hospitals in the context of the rapid social and cultural changes that the Iranians faced because of the implementation of the monarch’s reforms and the policies of centralization, statism, and social uniformity, the article puts emphasis on the fact that mission hospitals introduced a processual and negotiable type of medical modernity different from what was launched by the state at that time. Creating the healthcare networks in Iran, the Protestant hospitals produced the ideal—in the missionaries’ eyes—types of medical modernity that might be presented as the social and cultural roles played by patients, converts, and nurses.

1. Introduction

While announcing its medical policy in 1939, the Medical Commission of the Church Missionary Society presented a short description of a mission hospital as “a house of God, a place of healing for the sick, a school for the ignorant, and a home for the needy and unhappy” (Report of the Medical Commission 1939, p. 10). The document was issued with the purpose of outlining and formulating the rules for future medical work and, in the meantime, revealing and evaluating the progress of medical missions in the context of the social and political changes occurring in the various countries where the missions were conducted. Aware of the attention paid to healthcare issues by state authorities, the members of the commission emphasized that the “conditions in some countries are changing now, and Governments are organizing medical departments which are developing new hospital centers with all the equipment that science can place at their hospitals” (ibid.). Pointing at equipment and knowledge as part of modernizing medical centers, they postulated reorientation of the mission strategy and redefinition of the main goal that mission hospitals were supposed to achieve. The point was not to compete with state hospitals but to target people who received worse care from the state medical system. The report may be conceived as an example of negotiating purposes and possibilities, actions, and ideas provided by the missionary organizations in the frame of medical missions.

Reading the report in the light of the changes that were occurring in Iran during the reign of Reza Pahlavi (1925–1941), we may ask whether medical missionary initiatives were integral to the modernization policies and ideas of the state or rather contradicted them. Research has already shown that the impact of the state modernization policies was rather faint in the realm of medicine and limited to the elites and the army (Ebrahimnejad 2014, pp. 113–14). Thus, the hospitals established by the British and American Protestant missionaries in the period preceding the enthronement of Reza Pahlavi operated as the only institutions providing medical care in the regions where the scope of the state’s influence was insufficient. However, under the new program of centralization and unification, which was part of the “authoritarian modernization” of the monarch (Atabaki and Zücher 2004, p. 6), and the more active role of the state in promoting healthcare, the missionaries’ position diminished.

This article, by focusing on the Protestant mission hospitals in Iran during the authoritarian reign of Reza Pahlavi, raises questions on the functions of hospitals as religious and social institutions. The impact of the missionary-led medical enterprises on the Iranians experiencing rapid social and cultural changes should not be neglected. In other words, the article attempts to depict the ways in which the hospitals were represented in the missionary narratives in reference to the social and cultural transformations faced by Iranians in the given period.

What makes such a study different is precisely the emphasis on the transitional nature of the Protestant medical missions in Iran during the reign of Reza Pahlavi and its consequences for rethinking the missionary medical strategy and missionary identity. That means the necessity to characterize the main developments that shaped the missionary position. Among them one should mention at least (1) the governmental unification policy based on the linguistic patterns, which became both a challenge and a hope for missionary medical staff, (2) the governmental legal initiatives that regulated the medical market and medical professions, and (3) the growing Westernized Iranian middle class and the increase in the number of national medical practitioners. The medical missionaries in Iran were involved not only in the dichotomous relationship with the natives but also became part of the developing social networks that integrated at least some of the Western-oriented Iranians, native physicians (whether Muslims or Bahais), and the reformers eager to diminish the position of the foreigners. On the other hand, running hospitals involved meeting the expectations of patients representing various social strata. In this sense, the mission hospitals arose as places of negotiations and transfers. One should not neglect the global development of the Protestant medical missions as depicted in the report by the Medical Commission of the Church Missionary Society quoted above. That indicates the tendency to recognize the true needs and, in the meantime, to uniform the missionary policy towards healthcare issues in various countries of Asia and Africa. The premise is that mission hospitals introduced a processual and negotiable type of medical modernity widely different from the modernization project launched by the Iranian state.

The article attempts to situate mission hospitals in the context of the social and cultural changes that the Iranians faced as a result of the implementation of the monarch’s reforms and the policies of centralization, statism, and social uniformity. The reforms, perceived as a step toward modernization, were associated with the improvement of communication and transport networks with concurrent opening of the country to cultural, social, and technological influence from abroad. They were manifested in intensive urbanization and the state-sponsored project focused on the facilitation of medical care. The article is built on the assumption that mission hospitals creating healthcare networks in Iran produced or reproduced various types of medical modernity that might be attributed to the social roles played by patients, converts, and nurses. The main argument, however, is that a mission hospital was a place in between and a space of transfers and negotiations. Moreover, the article should be placed within the area of research on the history of Protestant missions in Iran as well as the cultural history of medicine.

Nikki Keddie (2006, p. 101) argues that the modernization efforts undertaken during the early Pahlavi era resulted in the phenomenon of “two cultures”, which was manifested in the social split and the differentiation between the new Westernized middle class and the traditional, religious part of the society. Regarding the development of medicine and healthcare, a similar tendency can be observed. Yet the strict division between modern and traditional medicine in the Iranian context appeared relatively late. Hormoz Ebrahimnejad (2014, p. 2) points out that “medical modernization was a multilayered process that involved not only Western influence and the introduction of modern techniques and concepts, but also an evolution in local medicine and the local medical profession”. What seems to have been intensified by the Pahlavi era is the medical discourse used for social and nationalistic purposes (Schayegh 2009, p. 6).

The activity of the Protestant missionaries in Iran, mainly Presbyterians and Anglicans but also Baptists, has become an attractive field of scholarly interests (Becker 2015; Francis-Dehqani 2000; Hopkins 2020; Rzepka 2017; Waterfield 1973) that has evolved into research on education (Zirinsky 1993; Rostam-Kolayi 2008) and women (Zirinsky 1992; Francis-Dehqani 2000). The problems of sanitary conditions and general healthcare referred to in the work of missionaries have been mentioned in valuable studies on womanhood, motherhood, and sexual policy in Iran (Afary 2009; Kashani-Sabet 2011). In recent years, however, the medical issues within the missionary work displayed a tendency to become an indented field of studies. Focusing on women missionaries in Iran, Gulnar Francis-Dehqani (2000) depicted the work of Emeline Stuart, a British missionary doctor, in reference to gender and power rations in the missionary field. Lydia Wytenbroek (2018) revealed the history of the American nurses and the growth of nursing as a profession in Iran. While analyzing the local circumstances of nursing work in a Muslim country, she, in fact, made a huge contribution to the field of global nursing studies. Willem Floor (2020), researching the beginning of modern medicine in Iran, emphasizes the role of American and British physicians, also including missionaries.

While analyzing the transfers of the Western models of modernity to Iran, Pamela Karimi proves that the influence of the Protestant missionaries was multifaceted and ambiguous. Although limited to, at least partially, Westernized Iranians, it shaped new attitudes towards consumerism and modern economies (Karimi 2013, p. 41). The scope of influence of the Protestant missions ranged from arousing social (or economic) expectations to promoting the education of women (also through the schools for nurses) to disseminate the principles of hygiene, all of which were strictly connected to the concept of modernity (Kashani-Sabet 2011, p. 123). The studies carried out on the changes that occurred at the turn of the 19th and 20th centuries shed light on the importance of reorientations in the field of medicine and the introduction of Western medical techniques in Iran as the main factor of modernization of the country (Ebrahimnejad 2004, 2014; Afkhami 2019).

While elaborating on the serai model of hospitals adopted by the British missionaries in India and depicting the process of building the mission hospitals in Iran, Sara Honarmand Ebrahimi (2023) shows that the hospital architecture embodied the main mission idea of gaining people’s attention. In the meantime, the hospital architecture evoked emotions and created a friendly, that is familiar, space for patients and potential converts. By using the conceptual framework of the history of emotions, she convincingly proves that the Iranian-style architecture adopted by the missionaries was meant to influence the Iranian patients. That is an interesting point that should be mainly attributed to the British hospitals at a certain moment of time—the evolution of the institutional medical work before the outbreak of the first world war. Finally, the research on modern medicine in connection to the Christian mission seems to have been attractive to the scholars who expressed a broader interest toward the history of the presence of foreigners in Iran and thus the history of Iran itself (Hājiān-pur and Bineshi-far 1395; Hamrāz 1391).

The aforementioned publications are grounded on the critical reading of the archival materials consisting of both missionary and diplomatic reports. What should be highlighted is the value of the missionary archives, which constitute an enormous deposit of documents. The diverse and scattered materials from the Protestant missions carried out in Iran from the beginning of the 19th century till the Islamic revolution of 1979 are stored in several institutions, like: (1) the Presbyterian Historical Society, Philadelphia, Pennsylvania (such materials refer to the hospitals run by the Presbyterian missionaries), (2) the Cadbury Research Library, University of Birmingham (they offer the materials concerning the Anglican mission hospitals), and (3) the Luther Seminary, St. Paul, Minnesota (materials concerning the hospital in Mahabad run by the Lutherans in frame of the activity of the Lutheran Orient Mission).

I believe that the process of negotiation and adaptation of the medical mission under certain national conditions can be estimated and measured by the close reading of the missionaries’ personal reports. A part of the huge missionary narratives, they offer a micro-perspective of the global process integrated into the local Iranian context. It should be emphasized that the personal reports, read as autobiographical narratives, set up a unique source of description and classification, a form of observation and categorization of the Iranian people and, at the same time, a kind of missionary autoethnography genre. The various missionary documents and materials need to be interpreted through an anthropological perspective (Comelles 1997). Conscious of the character of the missionary documents as one-sided narratives, we are careful readers looking at the archive through the goals pursued by the institution responsible for collecting reports—the missionary agency and the churches (Coello de la Rosa and Dieste 2020, p. 91; Renshaw 2013, p. 12).

Referring to the hospital as an “archetypal modernist institution” (Street 2011) in relation to the mission hospitals in Iran, we may focus on the tensions between the global flow of ideas and thoughts and their local adaptations. John Blevins (2019, pp. 86–87), analyzing the impact of American Christianity on global health and development policy, evokes the reports from the 1930s that referred to the main problems of that time: the negotiation of the meaning of the medical missions. The point was that they tended to become more humanitarian in style rather than evangelistic.

The characteristics of the mission hospitals allow us to use the micro-historic approach in the research, wherein, the micro-history is understood as a research attitude aimed at discovering and revealing local interdependencies and meanings. I suppose that such an approach has a lot in common with the anthropological “thick description”. Moreover, I am convinced that the micro-perspective does not necessarily exclude the object of the study from the wider system of references and processes. On the contrary, the micro-perspective allows one to show the heterogeneity of the studied communities in reference to the global process (various Muslims in Iran struggling with modernity, the flow of medical equipment, and so on) and, by focusing on individuals represented by patients, converts, and nurses, it gives an opportunity to depict how modernization was implemented locally (Conrad 2016, p. 131). Still, the works of Michel Foucault (2008) are used as inspiration, especially with regard to the power relations constituted by the hospitals. Similarly, the works of Susan Sontag (2009), which strongly contributed to the cultural history of medicine, are influential for considering the discursive strategies of the social construction of illness and pain but also the cultural representations of Iranian patients.

2. The Protestant Hospitals in Iran in Historical and Social Perspective

The first missionary attempts to introduce the Christian message to Iranians preceding the formal establishment of the mission was undertaken by Henry Martyn, an Anglican clergyman, who arrived in Shiraz in 1811. Although his work was predominantly focused on the Persian Bible translation, he made an impression on the generation of missionaries and laid the foundations for the future Anglican missions carried out by the Church Missionary Society. The work was officially recognized by the organization in 1869, when Robert Bruce was appointed as a missionary to Iran. At that time, the missionary activity was limited to the Armenian quarter of Isfahan—New Jolfa. With the arrival of Edward Frederic Hoernle, a physician who was considered the first Anglican medical missionary in the country (Report of the Medical Commission 1939, p. 8) in 1879, the work was expanded beyond New Jolfa. However, it was due to Donald Carr that the medical mission was fully implemented and, slowly, the hospitals run by the Anglicans began to operate. They were situated in Isfahan, Shiraz (the hospital was reorganized and rebuilt in 1923), Yazd, and Kerman. Their specificity was determined by the contacts with the British institutions operating in the southern part of the country (including the hospital in Abadan in the region of the Iranian oil industry). Some, like those in Kerman and Yazd, were situated on the trade routes to India.

Earlier, when the Anglicans officially recognized Iran as a mission field, the Americans from the American Board of Commissioners of Foreign Missions established their mission in Urmia in 1834. The mission, headed by Justin Perkins, was exclusively addressed to Christians from the Church of the East, popularly called Nestorians. Among the first missionaries of that mission, there was also a physician named Asahel Grant. In the 1870s, the responsibility for the work in Iran was transferred to the Presbyterian Board of Foreign Missions and the work was expanded to Tehran (1872), Tabriz (1873), Hamadan (1880), Rasht (1906), Qazvin (1906), Kermanshah (1910), and Mashhad (1911). The hospitals were built in most of the cities listed above: Urmia, Rasht, Kermanshah, Tabriz, Hamadan, Tehran, and Mashhad (Elder). Like other Presbyterian institutions, they were located in the northern part of Iran and, it seems, maintained close contacts with the representatives of the Iranian government and with religious bodies (Benjamin 1887; Brown 1936).

The history of Presbyterian hospitals in Iran starts with the hospital opened in Urmia in 1882 under the name Westminster Hospital (Speer 1911, p. 63). The hospital was run by Joseph Plumb Cochran, an American Presbyterian missionary and the son of a missionary, who was born in Iran. Having completed his medical studies in the United States, he returned to the country of his birth and became involved in promoting medical treatment among the local population. The hospital then became an impulse to intensify the work among Muslims (Kurds, Persians, and Turks), and its activities coincided with the wave of public health reforms prepared by the Iranian monarch Naser al-Din Shah (1846–1896). The work initiated by Cochran has been perceived as an example of Western influence on Iranian medicine (Ebrahimnejad 2014, pp. 129–30). Built in the area close to the Turkish (at that time Ottoman) border, the hospital was plundered during the first world war, reopened in 1922 (Ellis 1926; Brown 1936, p. 511), was shut down in 1934 for security reasons (Frame 1934), and later reopened again. It is hard to say that the hospital was typical, rather its character was shaped by the “transfrontier patients”. The same can also be said in reference to the only hospital run by the Lutheran missionaries. The Lutheran Orient Mission established in 1910 provided the evangelistic and medical work among Kurds in Soujbulak (nowadays Mahabad) and, under the leadership of Herman Schalk, a physician, the mission was able to open the hospital (Schalk 1925).

Obviously, every hospital, whether Anglican, Presbyterian, or Lutheran, had its own history, having been part of a certain missionary initiative and as such also part of Iranian modern history. All of them, however, shared common features and developments that can be described as follows: (1) the dependence on the regulations and law implemented by the Iranian authorities; (2) the interdependence between missionary organizations or missionary decision-making bodies and the interconnections of hospitals, manifested in transfers of personnel, equipment, and knowledge; (3) similar activities determined by the overarching idea of a hospital as part of evangelization project; and (4) similar initiatives regarding the idea of medical care addressed to women and training programs for nurses. Moreover, all of them were produced by a certain concept of a medical mission.

Medical missions became popular in the second half of the nineteenth century. Despite some objections to medical work (Hardiman 2006), the recognition of medicine as an integral part of evangelistic work started the unavoidable process of gradual transition from Protestant missions focused on salvation to missions with a greater concern for humanitarian aid. Such a process involved missionaries in constant deliberation on the purposes of establishing and running the hospitals and the meaning of their work (Gleeson 1993, p. 137).

Mission hospitals or, more precisely, medical missions were perceived by missionaries as the manifestation of modernization policy and as the embodiment of evangelical ideas. James Barton, defining the modern missionary, claimed that: “The power of the medical work is limitless” (Barton 1915, pp. 12–13). He referred to the involvement of the mainline Protestant churches in medical work and the development of hospital infrastructure in the missionary field. The work in Iran was, of course, part of such global initiatives. Dana Roberts says that for many Asian societies, the first contact with modernity was intermediated through the missionary Protestantism (Robert 2002). The forms of modernity brought by foreigners were modified, reevaluated, and assimilated by the native culture, which resulted in social activities and national feelings (Park and Yoo 2014, p. 6). Modernity demanded quite new practices that accompanied religious behaviors and manifested itself in new concepts of time, money management, and, finally, a new type of education and medicine.

From the very beginning, a mission hospital was a place of transformation. Such an idea was preserved from the early formulation of the medical mission and determined the missionaries’ self-perception, as well as the role the hospital played in education and the position of women (Williamson 1899, pp. 57–58). Henry Hodgkin (1919, p. 27), a missionary to China, pointed out that mission hospitals were a place for the transfer of new ideas. Such opinions regarding the special role of mission hospitals were, of course, shared by the missionaries working in Iran. They saw themselves as participants in building a new, modern Iran, at least in the field of medicine. However, the takeover of power by Reza Pahlavi marked the departure from the monopoly of foreigners, including missionaries, in healthcare.

It is hard to avoid political or imperial connotations of the Protestant missions. Compared to other countries, like India for instance, the situation in Iran was different. Iran had never been formally colonized. In consequence, the appearance of the missionaries—especially Americans—was not strictly connected to the political ambitions of the country they represented. Thus, the social activity of the missions was recognized by various Iranian governments. That should not be interpreted as an apolitical stance for the Protestants in Iran. Rather, we should bear in mind the various aspects of Western influence in Iran and the active position of Iranians who consumed the foreign ideas (Ebrahimnejad 2014, pp. 129–30). Again, the statement by Esme Cleall (2012, p. 76) that “the missionary thinking about both sickness and medicine helped to construct both Africans and Indians as others” is true also in reference to the Iranian context. In the simplified form, the physical healing led to spiritual renewal. This means that Muslims, as well as the representatives of other religious groups living in Iran, were treated in hospitals and evangelized at the same time. Thus, the narratives on conversions or at least the attempts to convert the patients to Christianity constituted the largest part of the missionary reports as the general history of the medical missions. The conversion, however, understood not merely as a religious category but rather as re-orientation and modification of one’s worldview, did not necessarily have to mean the rejection of Islam (or other faiths). Rather, it meant some modifications and changes in practices including religion that corresponded to one’s understanding and reception of what was perceived as modern. The encounter with modern medicine caused the first serious concern related to modernity: whether to believe more or to cure better. In a modified form, in the negotiated Iranian modernity, the concern was replaced by another one repeated frequently: how to believe and how to treat the sick?

3. Protestant Hospitals in Iran under the Reign of Reza Pahlavi: Negotiating the Missionary Presence

After experiencing the dynastic shift, the Iranians in the 1920s and 1930s did not only follow the path of technological and scientific advancement of the Western countries but also found their own way to modernization (Schayegh 2009). Undoubtedly, the Protestant missionaries, whether American or British, who established their mission in nineteenth-century Iran (Waterfield 1973, pp. 102–11, 133–76) contributed to the modernization process, cooperating in some areas with the state authorities while trying to gain independence from the Iranian state in others. One of the first fields of cooperation between the missionaries and the Iranian municipalities was the involvement in sanitary commissions in various Iranian cities (Floor 2020, pp. 260–61). The cooperation was not limited merely to such a problem but was expanded to other fields like education or public health. This is confirmed by the words of an American missionary doctor, Hartman Lichtwardt: “It is imperative that our mission hospitals and doctors take a definite part in this public health work and cooperate fully with everything constructive which the government is doing” (Lichtwardt 1930). He supposed that such a goal might be achieved only by the improvement of medical facilities and creating a network of hospitals that cooperated with each other and supported governmental medical reforms.

The missionaries seemed to have benefited from the political changes that occurred during the early reign of Reza Pahlavi. However, in the mid-1930s their position was diminished by the regulations issued by the government that limited foreign missionary work in such fields as education and medicine (Marashi 2008, pp. 92–97). The government, for instance, issued a regulation for the foreign physicians working in Iran requiring a five-year period of practicing medicine before their arrival to Iran. According to missionaries, such a demand was hard to achieve and complicated the process of the recruitment of new medical missionaries (Law 1933).

The missionaries witnessed contradictory state policy that favored the training programs for nurses provided by them while at the same time their work as foreign physicians was limited by new regulations. Nevertheless, in a certain period, the state contracted medical missionaries as teachers and examiners against the clergy’s protests. A good example is the work of an American missionary doctor Edward Blair at the newly established Anatomy Department of the Medical School (later the Faculty of Medicine, Pharmacy and Dentistry at the University of Tehran). Blair conducted anatomy classes (Floor 2020, pp. 60–62), against which, right after their appearance in the student curricula, Shiite clergymen protested, accusing Blair of offending Islamic values. Blair (1935) referred to dissection and pointed out that it became a theological problem among Muslims: “I will leave to Moslem theologians to discuss the question whether or not the prophet positively forbade anatomical dissection. There is no question, however, that Mohammedan tradition has effectively prevented it for the past 13 centuries’’. In the meantime, the Iranian government endeavored to improve the quality of medical education by sending Iranians to study abroad. The effect of such a policy was an increase in the number of qualified Iranian doctors and the establishment of state hospitals, which over time, as better-financed institutions, offered better diagnostic facilities. The increase in the number of Iranian professionals caused another complication, namely the protests of the local physicians against the foreign doctors (Thompson 1933).

Although the understanding of a hospital changed over time (Renshaw 2013, pp. 17–44; Rosenberg 1987, p. 11), its physical space, its location and architecture, played an important role in the identification of its functions and purposes (Renshaw 2013, pp. 45–46). It seems that during the reign of Reza Pahlavi, the mission hospitals in Iran no longer looked like the ones established some decades earlier. Rather, the hospital in its visual form represented the new modern idea manifested in architectural style. That might be explained by including the issue of property ownership acquired by missionaries in the analysis, which allowed them to purchase properties and build hospitals based on the modern patterns. Generally, the first phase of establishing mission hospitals in various regions in Iran was associated with the adaptation of private houses to medical purposes. Later, however, the hospital plans, along with the climatic conditions or seismic activity, were discussed by the American and British engineers and architects. Searching for appropriate solutions, the missionaries tried to adapt the models of the hospital work, admitting patients, the organization of hospital wards, or the sanitary system they were familiar with or modify such facilities in the Iranian context. During the 1930s, the American missionaries referred to the Mayo Clinic as a source of inspiration in organizing the hospitals’ work (Packard 1931; Hoffman 1932; Hoffman 1957), but even later they claimed the organization of the American hospitals may be used as a model in Iran (Cochran 1956). As in the case of architecture, the location of a hospital to ensure both the availability for patients and the development technical requirements was discussed by the missionaries.

The location of the mission hospitals in Iranian cities was the result of many factors, such as the distance to the existing mission building or the possibility of purchasing a suitable patch of land. Sometimes, however, personal contacts with the representatives of the Iranian local authorities could be decisive (Carr 1925). There is no doubt that the missionaries tended to interpret the hospital’s location in a rather providential way, especially when they started the mission in important religious centers. Rolla E. Hoffman (1925a), an American missionary doctor, describing the newly opened hospital in Mashhad in 1925 says: “The new hospital is one of the most imposing buildings of the city. On rather high ground, it is two full stories high; it is built chiefly of mud brick, but the front is faced with burnt brick and looks much like a large American brick house”. A full description of the hospital reveals the idea of how it was perceived by the missionaries—as a technologically advanced structure and how it could have been received by patients. Harriet B. Pease (1941), a nurse, referring to the visit in a hospital in Tabriz paid by a Muslim woman, pointed out that the building made a huge impression on her, saying that “An ignorant village woman, talking to a group of her friends after having received medical care in our hospital, said, ‘I’ve been to America and it is three stories high, and just like Heaven!’”. By no means was the purpose of the mission hospital to astonish people. But what made the difference was the functionality and ergonomic arrangement of the hospital space and the accessibility for an average Iranian patient. We may conclude that a mission hospital allowed Iranians to get used to the modernity imposed by the hospital architecture and the hospital interior design that was accompanied by the technologization of medical care. It is proved by the statement of Hoffman who, reporting on “the open days” in the hospital, says:

“Expressions of astonishment were constantly heard. The things that seemed to impress them most were the inclined plane—stairs without stops!, the orderly and convenient relations of the different departments—dispensary, pharmacy, laboratory, kitchen, laundry, operating suite, rooms for the hoped-for X-ray, women’s wards, men’s wards; the space up under the tin roof for hanging the wash on rainy days; the clean, orderly kitchen with its large stove that cooks the food and heats the water and oven, all with one fire; the in-patients,- their own neighbors,—in clean clothing and full of praise of their nurses and treatment; the seven private rooms, including a suite of two specially furnished and nice enough for anyone”.

(Hoffman 1925b)

Beside the description of the hospital interior, Hoffman stressed the location of the hospital, its rooftop overlooking the domes of the shrine of Imam Reza. The specific location in both the physical space (in the city center, in front of a Muslim shrine, etc.) and the imagined missionary geography makes one perceive the mission hospital as a place in between, which at the same time defined and blurred the boundaries of transformation and modernity. Bringing a “new religion” (the religion of missionaries, Protestantism), the hospitals acquired a set of research, observation, and diagnostic techniques and used sophisticated equipment and technologies (e.g., an X-ray machine) that might have been used by the missionaries to leave an impression among the Iranians that the religion they professed was in a sense rational and scientific.

In the popular Protestant imagination, those involved in the hospital work as medical workers, social instructors, and evangelists were all missionaries. That caused serious difficulties with distinguishing between what was seen by them as purely medical or religious. It raises a question on the attitudes towards Muslims and concerns whether a long-term presence in Iran helped to profile the missionary activity in more humanitarian terms. Lichtwardt (1929), who worked in Mashhad, in his report from 1929 expressed a rather general desire to promote health issues, saying that: “It is most encouraging to note this desire for the spread of health propaganda, and we shall continue to do all that we can to stimulate it and co-operate with the Persians in these matters.” He—like many other medical missionaries from that time—hardly distinguished between evangelistic and medical obligations. It should be stressed that the religious character of the hospitals shaped the forms in which medicine and healthcare were promoted. As the hospitals run by missionaries were named “Christian”, the medical staff were instructed to attend the religious services provided in hospitals. As a result, physicians conducted services and Bible classes and preached during Sunday meetings. The emphasis on participation in religious events was supposed to shape the patients’ perception that doctors were associated with Christianity. What is more, several activities promoting the Christian faith were carried out in the hospital—from individual talks to movie shows.

Apart from the institutional development and the function of the mission hospitals partly prescribed by the Iranian authorities, the individual missionaries’ self-descriptions revealed the problems of both the contextualization of the mission hospitals and his or her profession. Personal reports exemplify the missionaries’ self-reflexivity and their worries and understandings of the various contexts related to gender, social and political dependency, or the status of “others” among Iranians. Jeannette Jones (1931), an American nurse, started her report with the words: “Arriving in Persia several years ago I found nursing work quite different from what I had seen at home”. Of course, she referred to the nursing profession and the local Iranian interpretations of such work as nothing more than serving others. But still, she might have asked a question on what it would mean to be a Christian nurse working in a missionary hospital in a Muslim country. Nevertheless, she indirectly categorized a missionary hospital as a source of change, if not religious, then at least intellectual and social. The analysis of the personal reports prepared annually by a certain missionary shows the variability of positions and the overlapping time perspectives—current and retrospective referred somehow to the hospitals as a place of work. What was working in the hospital supposed to be like? Jones (1932), in her next personal report, wrote that seemingly the hospital work was almost the same everywhere “births, illness and deaths”. Saying that she was aware of something that was rather unusual in the state or non-mission hospitals in Iran, the Christian prayers, and services. One more aspect from her report should be mentioned, namely the cultural determinants of the categorization and understanding of illness and medical treatment. As the report was written in the 1930s, during the rapid modernization imposed by Reza Pahlavi, one may expect the ongoing process of the medicalization of Iranian culture. This meant that the mission hospitals began to resemble those run by the state. Such an opinion can be found in other missionary narratives.

From the perspective of his forty-two years of work as a medical missionary, Hoffman compared the beginning of his activity in Iran just after the first world war, when the only qualified doctors came from abroad, with the situation after the second world war, when the medicine in Iran developed, leaving little room for traditional medical missions. He says:

“The Iranian medical profession is increasing by leaps and bounds, both in numbers and in the quality of work done by many. Of course, the build-up is chiefly in Teheran, where today a Mission hospital is certainly not needed, except perhaps by the Church. Our doctors must identify themselves more with the leaders in the professions; Dr. Raji, Minister of Health, and Hashemian—surgeon in the new, highly equipped Cancer Institute, have four Resht nursing school graduates in their private hospital. Dr. Shaky, surgeon in the up to date Tuberculosis hospital, studied in our Tabriz Boys’ school. A Mission doctor located in Teheran would be able to develop the Mission relations with leaders, to advantage; yet most of our doctors visit Teheran frequently and they should not neglect the cultivation of personal relations with the Teheran profession”.

(Hoffman 1957)

The period preceding the dethronement of Reza Shah in 1941 heralded the end of the independent medical projects carried out by the missionaries and placed beyond the strict state control. It was a gradual process of the state absorbing and taking control over the Protestant initiatives related to medicine, while, on the other hand, it highlighted different political and religious attitudes towards modernity. By no means did the situation have an enormous effect on both the missionary initiatives and their self-perception. Firstly, they were subjected to the Iranian regulations and partly rejected as foreigners from certain social activities. Secondly, as recognized practitioners, they became competitors or colleagues of the Iranian doctors. In other words, they had to prove their professional skills and find new ways to attract Iranians. In my opinion, the tension from the state made them protagonists of new fields of healthcare, like baby clinics or schools for the blind. This also situated the mission hospitals in the space in between, as partly foreign and partly Iranian institutions, as they operated within the frame of Iranian law and they employed Iranians and served Iranian patients.

4. The Mission Hospitals: Producing Converts and Patients

The desire to reach as many people as possible involved the missionaries seeking new ways of advertising their medical services and improving the patient treatment they offered. The medical visits to towns and villages served such purposes and helped to popularize the idea of biomedicine and linked the visited people with a hospital represented by the doctors in their mobile dispensaries (Honarmand Ebrahimi 2023, pp. 41–52). The effect of such ventures must have been the introduction of a more relational dimension in patient–doctor interactions. Indeed, the personal reports by the medical staff confirmed the patient-oriented work and an attempt to understand the disease in a broader context of a patient’s biography and with reference to their social conditions.

The orientation toward patients resulted in two tendencies: to present “special cases” and extraordinary biographies of patients and to prepare the statistics concerning the number of in-patients and out-patients with information of the operations completed in hospitals. Let us take a piece of information given by an Anglican missionary from 1937 regarding the number of patients treated in the mission hospital in Kerman, an important city on the route to India. The number of patients who visited the hospital exceeded—according to the published records—30 thousand (Hoare 1937, p. 65), which, when we take the total population of the city (around 40 thousand) into account, seems to be very impressive. The report is just raw material that hardly helps to understand the real flow of patients. Nevertheless, one of the powerful changes introduced to medical missionary practice in Iran—improving the data collection and statistics—was the implementation of the record system in mission hospitals. It improved the doctors work but was beneficial to a patient too. Lichtwardt (1931), in his personal report, explains the idea: “As we simultaneously decreased our inpatient work, we were able to give much better attention and care to those we admitted, and each individual now receives a detailed physical examination from head to foot—which with the details of his family history, past history and present illness is all written up as part of his record and is very useful, especially if he returns to the hospital at some later time”.

Again, it should be emphasized that in a religious institution such as a mission hospital, the record system was used also for religious purposes. The examination of one’s health would be transformed into a conversation on the meaning or value of life. Indeed, from the missionary perspective, collecting an individual’s medical data could be useful in sharing religious Protestant ideas. Hoffman had evangelistic purposes in mind while introducing the record system in Mashhad. He decided to employ Rabi Paulos Sahda, an Assyrian from Urmia, as a hospital evangelist and a record clerk. Hoffman described him as a first-contact person in hospital who spoke five languages. Paulos was responsible for collecting information about patients, indexing them and, in the case of returning patients, checking their medical documentation, and collecting fees for medical treatment (from those who could afford it). Hoffman (1925a) says: “It has proven a satisfactory solution to the problems of keeping records and of telling the patients of Christ and is now financed from general budget as an essential part of the hospital’s program. Thru saving the doctor’s time and enabling us to maintain a higher standard of work, it has been a factor in increasing income”. Yet, the question remains as to what attitudes and reactions the hospital evoked among those who visited it.

From the very moment of its appearance, a modern hospital shaped new attitudes and practices that were manifested in simple activities like taking medicine or naming the illness, as well as in more sophisticated ones such as the hospital treatment. The analysis of the missionary materials proved that the apparently obvious relations between a doctor and a patient had unexpected effects in the Iranian context. The hospitals introduced concepts that were rather vague to an average Iranian, measures of time and space and a new category of body and health. They, as it is taken for granted among the missionaries, constitute the desirable features that the ideal patient should possess to be effectively treated and finally recover. Thus, initially, the missionary doctors aimed at transforming the Iranians into (ideal) patients. It was challenging to teach the people when and how to take the medicine as “many do not follow directions”—lamented one of the missionaries pointing out the cultural differences that they faced in Iran (Speer 1911, p. 61). Another problem was communication in the multi-ethnic Iranian society, tempered somehow during the implementation of the linguistic policy during the reign of Reza shah. Yet in 1931, Frame (1931) enumerated the difficulties saying: “Trying after all these years to get across to our patients the help we could give them if only they could be made to understand and follow the instructions, we try to give them. This starts with a language difficulty. Each dispensary day sees forty or more poor ignorant people speaking a variety of languages: Persian, Turkish, Armenian, Russian or one of the weird mountain dialects.” The positive aspect would be gathering various people under the roof of the mission hospital. Thus, the hospital served as a place of integration in the broadest sense.

The process of forming (or generating) patients—to paraphrase the quoted missionary those who know when and how to take the medicine—indicates various cultural strategies of assimilation of new ways of treatment, concepts, and technologies introduced by the missionaries among the Iranians. Mable Nelson, a nurse, in her report from the period 1931–1932, suggests that the mission hospital was often not the first-choice option:

“Our patients as a rule try first the old remedies to counteract the influence of the evil eye, then the neighbors offer suggestions, leaves and petals are brewed, poultices of various kinds and mixtures, are applied, aid of village and city Persian doctors is requested, finally they try the American hospital (…). They seem to us a little peculiar, but then so do we to them with our foreign ways, no we must win confidence, exact obedience to doctor’s orders, and show them what kind nursing care can do”.

(Nelson 1932)

Missionaries listed the stereotypes, opinions, and prejudices that the Iranian patients expressed while they experienced hospital treatment and attempted to rationalize the new medical ideas within their own culture (for example through prophetic dreams), which led to gradual acceptance and assimilation.

Probably the most significant and highly expected change the missionaries wished to achieve in Iran was of a religious character, the religious conversion, patients treated in the mission hospitals embracing Christianity. An Anglican missionary tried to persuade his readers that “a large number of converts first heard the glad tidings when they were ill in hospital or were visiting friends there” (Hoare 1937, p. 56). The statement “a large number” is insufficient and does not give an explanation of how and why the patients rejected Islam. Regarding a mission hospital as a religious institution, it should be assumed that it aimed at converting. In the early years of her work in Isfahan hospital, Emeline Stuart (1908, p. 3), a British missionary doctor, wrote about the conversions among women: “Now in 1907 we have between seventy and eighty women converts and the majority of them are, directly or indirectly, the fruit of the Medical Mission”. She also defined, in a rather poetic manner, a mission hospital as “a birthplace of souls”. In a sense, the hospital stimulated the process of reconstruction or recreation of one’s biography through the personal experience of medical treatment provided by Christian partitioners. It seems, however, that the strict connections between being treated in mission hospitals and the change of religious practices and religious affiliations was exaggerated by missionaries. That is why the conversion in or through hospital would be categorized as a form of orientation that required acceptance of a new identity redefined in the light of modernity. Despite the triumphal tones in the missionary publications, most of the patients did not abandon their faith. Still, the question remains how and to what extent the mission hospitals influenced the religious practices and religious worldviews of Muslims. One of the women missionaries and doctors referred to such a case from the hospital she was working in: “Mastoidectomy on a son of a religious man—the father stayed in the room part of the time, praying, and holding the Koran wrapped in a cloth over his head as the anesthetic was given” (Frame 2014, p. 45). She pointed out that practices that were performed in a new context might undergo some modifications and adaptations to hospital conditions, including the attitudes towards anesthetization. The religious practices performed by Muslims in a Christian hospital that aimed at the familiarization of what was culturally different led to negotiations of what would be considered religious or not religious. Without doubt, every “hospital contact” was, in a sense, imprinted in the individual biography of patients and resulted in the modification of behavior or thinking. The encounters with the missionaries interfered in the relations inside the families and shaped the general attitudes towards the modernization processes. Thus, the activity of the hospitals should be understood as complex medical, social, and religious actions that included observation (diagnostic practice), treatment, promotion of healthcare, and assistance for experiencing social problems (like drug addiction) defined as such, not only by missionaries but also by Iranian activists and reformers (Ghiabi 2019, p. 46).

Discussing the problem of religious conversion, it is the social character of such an act that should be emphasized. What is more, a stronger individualization of religious practices that resulted in a greater inclination to make decisions of conversion seems to be, paradoxically, more characteristic of women. In the missionary materials, we may find information on hospitals that served as places of refuge for women abused by their husbands. Nevertheless, the conversion was a form of emancipation and, when the conversion was committed in a hospital, the hospital became a working place for some of the converts. It is another aspect of the sphere of mission hospitals’ social influence. The conversion was, in fact, a reproduction of missionary values and reconstruction of one’s biography according to certain patterns introduced by medical work. In the reports, persons such as Dr. Kurdistani, a Kurdish physician, or Dr. Hazeq were mentioned. The latter was described by John Elder (1936), a veteran American missionary, as “the converted physician, whose dynamic enthusiasm and radiant faith opened new vistas of opportunity for evangelistic growth”. It is therefore not surprising that Iranian doctors and nurses from Muslim backgrounds became the best exemplification of the work of mission hospitals.

The changes that occurred in Iran during the reign of Reza Pahlavi can be measured by the social position of women. Following the suggestions that the growing position of women in Iranian society was directly related to the dissemination of the principles and regulations concerning health and medicine (Kashani-Sabet 2011, p. 48) as well as the promotion of education among women, it is impossible to lose sight of mission hospitals. Firstly, because of the missionaries’ aims at imitating and coordinating the project on healthcare addressed to ordinary Iranians in order to raise the awareness of general medical issues, hygiene, and disease prevention. One of the missionaries expressed their engagement in the “promotion of vaccination, cholera prevention, care of the teeth, care of babies, care of tuberculous patients in the homes” (Hoffman 1957). Secondly, because the missionaries were able to transfer the knowledge needed for instructing practitioners to Iran. Of course, the teaching of modern medicine in Iran was sponsored by the state from the middle of the 19th century, but nursing education was almost exclusively a missionary domain practically till the 1930s (Brown 1936, p. 59; Wytenbroek 2018). The governmental support for the nursing schools run by missionaries at that time can be seen in the context of the official policy of modernizing society, which was manifested, in relation to women, in implementation of the law against wearing Islamic chadors. Consequently, the changes resulted in the growing authority of women in some aspects of social life (a good example being the culture of motherhood). It is obvious that such processes were implemented gradually and with different intensities among various groups in Iran. The nursing profession was integrated with the modernization policy and as such caused deep cultural reorientation of the whole Iranian society. Pointing out the education of Iranian women and their engagement with the mission hospitals’ work, it is worthwhile emphasizing once more the importance of the study of the religious conversion committed by women as a marker of social changes occurring locally. Probably the best-known Iranian convert, the late Anglican bishop Hassan Barnaba Dahqani-Tafti, recalling his mother, states that “she was a nurse and, despite her scant knowledge of medicines, ran the dispensary” (Dehqani-Tafti 2000, p. 9), proving the local model of reproduction and dissemination of medical practices (and religious attitudes) by women.

We may assume that while running hospitals, the missionaries aimed at the transformation of individual as well as communal life. The hospital was idealized as a place of professional medical treatment and, at the same time, a religious institution. It was a place in between the intermingling cultural orientations of missionaries and Iranians. What should be emphasized is the impact of the transformative character of the reform movement during the reign of Reza Pahlavi. The processes and changes that occurred at that time also influenced the missionary self-perception and their missionary work and were strongly associated with new forms of medical treatment and hospitals that were perceived as a significant tool for the modernization of the whole society (Hoffman 1933).

5. Conclusions

The statement from the report by the Medical Commission of the Church Missionary Society describing a mission hospital as “a house of God, a place of healing for the sick, a school for the ignorant, and a home for the needy and unhappy”, corresponds with medical missionary ideas and practices in Iran during the reign of Reza Pahlavi. Focusing on the personal reports, we reconstruct the gradual transformation of the self-categorization and the position of the Protestant missionaries in the field of medicine in Iran. Thus, the reports, read as cultural texts, give evidence of the first attempts to define the rules and practices of what was much later named transcultural medicine. Generally speaking, the missionary doctors were obliged to accept the cultural and social backgrounds of people who, through the modern hospitals, experienced previously unknown forms of the rationalization of treatments (to some extent pharmacological and surgical) and mechanization of medicine. Modern medicine, therefore, required reorientation of the attitudes of both those who accepted the forms of treatment and those who opposed them. The social and cultural reorientations of the Iranians are measured by the study of the negotiations of the roles defined as patients, converts, and nurses.

It should be emphasized, once again, that a modern hospital—the mission hospital should be perceived as such—is a harbinger of modernity initiated by social changes. It aroused as much reluctance among the conservative, Muslim part of the society as admiration among those who saw the sources of modernization of Iranian society in Europe or in the United States. In any case, the reforms of public health that were initiated from above by the state had, initially, a minimal effect on the population living in the areas stretching away from the administrative centers, whereas the mission hospitals situated in the undeveloped regions played an important social role despite the opposition of the clergy and had enough potential to disseminate modern medical care with their own understanding of religion and religiosity among the Iranian people.

We may conclude that the mission hospitals played an important role in introducing quite new methods of treatment and medical science, demanding at the same time a slightly new understanding and categorization of the human body and religion. It seems that the mission hospitals, which made the new science and medical technology available to an average Iranian citizen, questioned the old, but commonly accepted, traditional practices and healing methods. Providing medical care, the Protestant medical missionaries intermingled their religious beliefs with the technological advancements of the countries of their origin, so the hospitals they established were perceived by the Muslims as religious institutions. As such, they influenced certain social, religious, and legal regulations. Mission hospitals were religious institutions linked to the missionary organizations and financed by missionary agencies. Operating in a Muslim environment, the mission hospitals in Iran should also be described as places of transformation and hybridization.