Dr. Sister or Sr. Doctor? Charting the rise of sisters who minister as medical doctors in India

“In a land where hearts beat strong and true, Emerges a sisterhood, a remarkable crew.
They wear their white coats with pride and grace, sister doctors, healers in every case.
In rural villages, far and wide, they journey on, bridging the divide.
Reaching the underserved, the ones in need, sister doctor plant a caring seed.”
- Poem by Sister doctor

In an age where health care is increasingly looked upon only as profitable business, an encouraging trend has emerged in India of Catholic religious congregations educating their sisters to study medicine and become Sister Doctors. In the United States, and also in India, it is difficult to get medical doctors to practice in rural areas and to get health care institutions to serve those without the financial means to pay full price for treatments. Countering this trend, 85% of India’s Catholic Sister Doctors serve in rural areas in facilities often supported by their congregations as these are areas where the institutions are unlikely to bring in enough capital to meet their bills without some outside sources of funding, such as the central, North East, Andhra Pradesh, Telangana, Karnataka, Tamil Nadu and Kerala regions.

These Sister Doctors provide curative, promotive and palliative care service and thus contribute to restore the health and wholeness of the people who live in the medically underserved areas of our great nation. They follow the footsteps of the divine healer with great passion for God and compassion for humanity. In addition, they usually work with Sister Nurses from the same congregation and they live and work together.

The trend is for the number of Sister Doctors to rise.  In 2013, according to the Sister Doctors Forum in India there were 537 registered.  In 2023, they report 723, an increase of 35%.

As my current research at CARA has been finding, it is the congregations themselves who have spurred this growth. Although it is a preliminary finding, at present, 77% of the Sister Doctors I have been interviewing say they were asked by their congregations to study medicine and become doctors, rather than having entered religious life wanting to be doctors. As one Sister Doctor notify: “To me personally had no desire to be a doctor, my desire is to become a nurse to serve the sick and suffering, but I was asked by my authority to become a doctor and work in a rural area. I said ‘Yes’. Became a doctor and working in a remote rural area serving the poor. I am very happy in my ministry”.

The ministry of sister doctors is true evangelization.  Christians in India make up only 2.5% of the total population. Such a statistic can be deceiving, however. In 2021, there were 1.4 billion Indians, making for an estimated 35 million Catholics. Frequently serving the poorest of the poor, the health care they provide is most often to people of other faiths (Hindu and Muslim patients).  

Breaking free from societal expectations and traditional gender roles, these extraordinary women have embarked on a path less traveled, paving the way for a brighter, more inclusive future. Their rise not only represents a significant shift in the gender dynamics of the medical profession but also highlights the immense potential and determination of women in Indian society. As one Sister Doctor I interviewed noted: “I think that passion is the secret ingredient that drives hard work and excellence”.

The Sister Doctors have specialized in various fields of Medicine like Cardiology, General Medicine, Surgery, Pediatrics, Gynecology & Obstetrics, Radiology, Psychiatry, Pathology, Family Medicine, and Public Health Medicine and other streams like AYUSH, and Naturopathy.

They also face challenges being Catholic and serving in public hospitals, being asked to perform procedures not approved by the Catholic Church as One Sister Doctor described it: To follow Church obligations vs governments laws are very difficult.

Being both a sister and a doctor presents some unique challenges, however, being on call and treating a patient overnight and being expected to participate in the prayer, social, and communal life of one’s community where they live and work can pose real problems for the Sister Doctors. As one noted: No leave, no outing, 365 days’ work, have to participate in all religious activities and work, so no our own time, no updates. I find it difficult to spend quality time in prayer while I'm able to work day and night unceasingly. So, in the process I compromise on prayer in exchange for work.  That leaves a deep dent in my conscience and in my commitment.

That said, 87% of the Sister Doctors I have surveyed up to present say they would again choose to be religious sisters and be doctors if they had the choice. According to our preliminary findings, over all, almost all sister doctors are satisfied with their ministry as a medical doctor. Nine in ten of the responding sister doctors have a sense of contribution to the larger purpose, a sense of personal accomplishment, and are satisfied with support they receive for their current ministry.

As this is an upward trend, we think you’ll be hearing more about Sister Doctors in the future as their presence, ministry, and impact continues to influence. India, the world’s most populous nation and thus the world at large.

This blog was written by CARA Visiting Scholar Sr. Mini Joseph, JMJ.

A Decade of Pope Francis

How has the Catholic Church changed in the 10 years Pope Francis has led the Catholic Church? It is difficult to say.

The first issue is that we always have lags in data. The Official Catholic Directory (OCD), which provides statistics for the United States is published each year in the Fall and represents the Church on January 1^st of that same year. But the sacraments data in that volume represent the year prior. The current edition for 2022 gives a view of sacraments celebrated in 2021. The Annuarium Statisticum Ecclesiae (ASE) provides global data from the Vatican and this has an even longer lag. The current edition is for 2020. So we can compare the data measuring 2013 to the current volumes for the U.S. and the world but then we run into the second and I might say bigger problem...

Remember this time three years ago in 2020? Yeah. The world changed and has not yet returned to the “normal” of 2019. Any impact, positive or negative, Pope Francis may have had will be overshadowed by the effects of the COVID-19 pandemic when our most current data represents 2020 and 2021. We know looking at Church data for these years we are going to see lower levels of Mass attendance and sacramental practice with the impact of lockdowns, restrictions, and hesitancy for people to gather in crowds in enclosed spaces during those two years.

Globally, if we compare 2013 to 2020, the Catholic population grew by 8.4% from 1.254 billion to 1.360 billion. The number of diocesan priests is virtually unchanged (11 fewer in the world). The number of permanent deacons has increased by 13% to 48,259 in 2020. On the negative side the number of religious sisters and brothers continue a long decline (-11% and -9%, respectively). There were 74,029 fewer sisters and 4,684 fewer brothers in 2020 than in 2013. The number of parishes increased by 1,480 to a world total of 224,376 (for context there are 280,521 diocesan priests).

Now for the really bad news with that COVID-19 asterisk and another longer term surprise. The number of annual baptisms declined by 2,021,627 (-13%) in 2020 compared to 2013. The number of marriages declined by 702,246 (-27%). Confirmations and first communions also dropped (-12% and -13%, respectively). Yet, there is something more than a pandemic affecting these numbers. They’ve been in decline for some time even as the Catholic population grows. How does that math work?

In the last 60 years, we have seen a dramatic demographic transformation of the world’s population. According the World Bank’s World Development Indicators (WDI), life expectancies at birth have been increasing globally from 51 years in 1960 to 72 years in 2020. At the same time, the birth rate (per 1,000 people) has fallen from 32 in 1960 to 17 in 2020 (we've covered this before). Our population “pyramid” is losing its base and evolving into more of a “pole.” According to the United Nations Population Division, in 2013, there were an estimated 143 million births around the world. There were 138 million in 2019 and 135 million in 2020. The number of births is expected to decline annually into the foreseeable future eventually being outnumbered by deaths in 2085 according to U.N. projections. The population will grow in the decades ahead as life expectancies continue to increase but at the same time births will decline and that will result in fewer baptisms, fewer first communions, fewer students, and yes even fewer marriages annually just by the numbers of the demographic shift we are experiencing. 

As far as we can tell, Mass attendance has remained fairly stable absent the interruptions of the pandemic and lockdowns. We can compare the sixth and seventh wave of the World Values Survey (WVS). The sixth wave was conducted from 2010 to 2014 and the seventh from 2017 to 2022. There are thirteen countries surveyed in both waves allowing for comparison. These countries were home to 516 million Catholics in 2020 representing 41% of the global Catholic population.[1] Looking at the responses to the survey by the Catholics surveyed in the WVS and applying this to those countries Catholic populations we can estimate that Mass attendance was unchanged from the 2010-2014 surveys and the 2017-2022 surveys (at 45% for weekly attendance in the aggregated sampled countries, ranging from 14% in Germany to 94% in Nigeria). Yet the number of Catholics in these countries increased during the time between the sixth and seventh waves resulting in a 7% increase in weekly attenders. For more on global Mass attendance see our previous post. 

Now turning to the United States, it is important to put in context that only 5% of the world’s Catholics live in this country. If one were to evaluate changes in the Catholic Church, a more global lens would always be recommended. With that said, things are not going as well in the United States as they have globally.

According to the General Social Survey (GSS), weekly Mass attendance among Catholics in the U.S. declined from 25% in 2012 to 17% in 2020-21. We have seen similar trends in our own tracking but are also seeing a rebound to 2019 levels in more recent polls and measurements. Daily prayer declined from 59% to 51% from 2012 to 2020-21. Unlike Mass attendance, one can pray at home and this should not have been affected by the pandemic. If anything, one might think Catholics would be praying more often  during that time.

Looking at statistics from the OCD, there is a consistent pattern of declines across nearly every available measure in the United States when comparing the 2013 and 2022 volumes. The number of diocesan priests is down 8%. There are 27% fewer sisters (-13,581), 19% fewer brothers (-802), and 15% fewer religious priests (-1,775). The one positive measure is an increase in permanent deacons from 17,473 to 18,043 (up 3%).

With fewer clergy there are also fewer parishes. These have declined from 17,472 to 16,429, a 6% drop. Although the number of missions grew by 3% adding 60 sites. There are declines in Catholic schools and the numbers enrolled in them with the exception of one outlier. The number of private Catholic elementary schools increased by 8% and the number of students enrolled in them by 14%.

The analysis of U.S. sacramental data mirrors the global trend. As the Catholic population remains essentially stable, 66.6 million in 2013 compared to 66.5 million in 2022, the number of baptisms (-299,975), first communions (-220,540), confirmations (-67,683), and marriages (-55,239) fell during the same period. It is important to note again that the 2022 OCD is reporting sacramental data from earlier during the pandemic. Even with the aforementioned demographic shifts occurring we would expect the numbers for that year to be dismal. Although it should be noted that the 2022 OCD figures are improvements of the what was reported in the 2021 OCD.

In sum, no one should be giving Pope Francis a 10-year report card based on the most current data available and when more comparable post-COVID-19 data are available, any “grades” given for changes in the number of sacraments celebrated should be considered within the context of what is happening demographically across the globe.

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[1] These countries include: Argentina, Australia, Brazil, Colombia, Ecuador, Germany, New Zealand, Nigeria, Peru, Philippines, Poland, Slovenia, Spain

Where Is Mass Attendance Highest and Lowest?

Which country has the highest Catholic Mass attendance? We can’t say for sure because surveys have not been conducted on the topic in every country in the world. The World Values Survey (WVS) is in its seventh wave (beginning in the 1980s) and has data for 36 countries with large Catholic populations. Among these, weekly or more frequent Mass attendance is highest among adult self-identified Catholics in Nigeria (94%), Kenya (73%), and Lebanon (69%). The next segment of countries, where half or more Catholics attend every week includes the Philippines (56%), Colombia (54%), Poland (52%), and Ecuador (50%). Fewer than half, but a third or more attends every week in Bosnia and Herzegovina (48%), Mexico (47%), Nicaragua (45%), Brazil (44%), Bolivia (42%), Slovakia (40%), Italy (34%), and Peru (33%). Click the image below to see a larger version.

Between three in ten and a quarter of Catholics attends Mass every week in Venezuela (30%), Albania (29%), Spain (27%), Croatia (27%), New Zealand (25%), and the United Kingdom (25%).

In CARA’s polling, about 24% of Catholics in the United States attended Mass every week or more often prior to the COVID-19 pandemic in 2019. In our most recent poll in late summer 2022, 17% of adult Catholics reported attending Mass this frequently with 5% watching Mass online or television from home instead. Other countries with similar Catholic Mass attendance as in the United States are Hungary (24%), Slovenia (24%), Uruguay (23%), Australia (21%), Argentina (21%), Portugal (20%), the Czech Republic (20%), and Austria (17%). The lowest levels of weekly attendance are observed in Lithuania (16%), Germany (14%), Canada (14%), Latvia (11%), Switzerland (11%), France (11%), and the Netherlands (7%).

One might assume that the more religious Catholics are in a country, the more likely they are to be frequent Mass attenders. Yet, there is not a strong correlation between the numbers identifying as a "religious" Catholic and frequent Mass attendance (an R2 of .097).

The WVS asked respondents, "Independently of whether you go to church or not, would you say you are…  A religious person, not a religious person, an Atheist, or don’t know." The scatterplot below shows the relationship between the percentage of Catholic respondents in a country identifying as a religious person and the percentage indicating that they attend Mass once a week or more often.

There are countries where there is a close relationship between answers to both questions including the Netherlands, Brazil, Argentina, Ecuador, the Philippines, Kenya, and Nigeria. But for many other countries their placement is far from the regression line. Lebanon, for example, has very high Mass attendance, comparatively speaking, but the share of Catholics there considering themselves to be religious is substantially lower in comparison to other countries. Ninety-seven percent of Catholics in Uruguay consider themselves to be a religious person, yet only 23% of Catholics there attend Mass weekly or more often. Click the image below to see a larger version.

Other than Uruguay, the countries where Catholics are most likely to consider themselves to be religious are Nigeria (95%), Albania (94%), Slovakia (93%), the Czech Republic (92%), Italy (92%), Lithuania (92%), Kenya (92%), Colombia (92%), Bolivia (91%), and Poland (90%).

More than three-fourths but fewer than nine in ten Catholics in the following countries consider themselves to be a religious person: Croatia (88%), Bosnia and Herzegovina (88%), Slovenia (87%), Hungary (86%), Portugal (85%), Latvia (85%), Peru (84%), Philippines (83%), Ecuador (82%), Brazil (82%), Argentina (79%), the Netherlands (78%), Mexico (77%), and Nicaragua (76%).

Catholics in the United States come in just under this group with 74% considering themselves to be a religious person. The U.S. is followed by France (72%), Austria (69%), Australia (67%), Spain (67%), Germany (65%), Switzerland (63%), Lebanon (62%), the United Kingdom (59%), Venezuela (57%), Canada (55%), and New Zealand (55%).

In terms of identifying as a religious person, Catholics in the United States and France are quite similar (74% and 72%, respectively). Yet, only 8% of Catholics in France attends Mass weekly compared to 17% of Catholics in the United States (and 24% attending weekly prior to the pandemic).

While there seems to be a disconnect between identifying as a religious person and attending Mass weekly there is a third factor that may explain the comparative distribution of both of these attributes. If you’ve looked closely at the countries you might have noticed some economic clustering.

GDP is the total value of all goods and services produced in a country in one year. When you divide this by the population you get GDP per capita, which is the standard measure of the average comparative wealth per person between countries (data: World Development Indicators, World Bank). 

The fit between GDP per capita and frequency of Mass attendance is stronger than religiosity and Mass attendance (R2 of .6107), albeit in a curvilinear relationship. Mass attendance falls sharply as GDP per capita rises to $10,000 and then this drop slows and flattens as GDP per capita continues to increase. This scatterplot has some outliers. Lebanon, for example, is quite distant from the regression line with lower than expected Mass attendance and Italy has nearly the opposite with higher attendance than would be expected using GDP per capita as a predictor.  

Religiosity has a more linear, yet weaker, relationship with GDP per capita (R2 of .4365). There is a large cluster of countries with GDP per capita less than $25,000 that have among the highest shares of Catholics self-identifying as religious. In higher income countries, religiosity falls. There is a cluster of countries in Western Europe, North America, and Oceania with lower levels of religious self-identification. Switzerland, with the highest GDP per capita of the countries surveyed, has both low levels of weekly Mass attendance and relatively smaller numbers of Catholics self-identifying as religious persons. In this scatterplot, Lebanon is the most significant outlier with lower than expected levels of religious self-identification.

In this small sample of countries, we can surmise that Catholicism is strongest in what is often called the developing world where GDP per capita are lower, while it appears to be contracting in wealthier "developed" countries. The precise mechanisms associated with economic development and wealth that are impacting Catholics' participation in the faith and identification as religious are unclear. Whatever they are, they matter significantly.

Note: In survey research, self-reported frequencies of Mass attendance can be inflated by social desirability bias. However, this bias may be relatively similar across populations. Thus, the differences between countries in attendance are likely accurate although actual Mass attendance levels may be lower than reported. Nigeria has the highest share of weekly attenders at 94%. According to the Annuarium Statisticum Ecclesiae 2020, Nigeria was home to 32,576,000 Catholics and 4,406 parishes. With the reported frequency of attendance there would be 6,920 weekly attenders per parish. This would require numerous Masses each weekend. Kenya is home to 16,467,000 Catholics in 6,353 parishes. Taking account of their reported frequencies of Mass attendance this would result in 1,900 weekly attenders per parish, which is not unreasonable.

 Creative Commons image of a Catholic Mass in Abuja, Nigeria courtesy of Jeremy Weate.