Fam Community Health Vol. 37, No. 3, pp. 223–230 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Women, Religion, and Maternal Health Care in Ghana, 1945-2000 Lauren Johnson, BSN; Barbra Mann Wall, PhD, RN, FAAN This article documents the historical factors that led to shifts in mission work toward a greater emphasis on community health for the poor and most vulnerable of society in sub-Saharan Africa after 1945. Using the example of the Medical Mission Sisters from Philadelphia, Pennsylvania, and their work in Ghana, we challenge the conventional narrative of medical missions as agents of imperialism. We assert that missions—particularly those run by Catholic sister physicians, nurses, and midwives—have changed over time and that those changes have been beneficial to the expansion of community health, particularly in the area of improvement of maternal care. Key words: Alma Ata, mission, primary care, sub-Saharan Africa
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N DESCRIBING her midwifery work in rural Ghana, Sister Rose Kershbaumer, a Medical Mission Sister, stated,
We started out hospital based . . . . Very early in Ghana, we started what we called “treks.” And we’d go out to the village for antenatal care, for “under five” clinics, so we have always been outside the hospital . . . . You need a place for acute care . . . . You have to send in your referrals. And you have to identify problems. But we have always been strong on community. (Sister Rose Kershbaumer, in an interview with the authors, May 10, 2012)
Sister Rose’s comment emphasizes community health in the mission work of Catholic sisters. Yet, their contributions have been overshadowed in historical literature by a focus on Author Affiliation: School of Nursing, University of Pennsylvania, Philadelphia. Funding for this research was provided by the University of Pennsylvania Urban Research Institute Award, the University of Pennsylvania School of Nursing’s F(our)ULD Undergraduate Research Award, and the University of Pennsylvania URF and Vagelos grants. The authors declare no conflict of interest. Correspondence: Lauren Johnson, BSN, School of Nursing, University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA 19104 ([email protected]). DOI: 10.1097/FCH.0000000000000032
the colonial era and interpretations of hegemonic, imperialist themes. Conventional accounts of the history of nursing and health care in sub-Saharan Africa have indicted Christianity and biomedicine as tools of European colonial expansion.1-5 Medicine was interpreted as a means to evangelize and attain willing converts. According to this interpretation, missionaries viewed the “sickbed” as the most receptive time in a person’s life to surrender to the will of God. Megan Vaughan’s Curing Their Ills is especially insightful for its analysis of Protestant medical missionary discourse, primarily British, during the colonial era and its representations of African culture and patients. In her analysis, missionary rhetoric revealed that medical mission work “was part of a program of social and moral engineering through which ‘Africa’ would be saved.”6(p74) While Vaughan is sensitive to the problems of using missionary language as evidence for actual encounters on the ground, her work and others have held lasting influence among both popular and academic audiences. This depiction of missionaries as agents of imperialism has largely been left unchallenged, which perpetuates the idea that missions have remained imperialist since their beginnings. While evangelism was the primary focus of missionaries in the precolonial and 223
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colonial periods, their focus has shifted over the last half of the 20th century to one of service and social justice, including greater concern for the poor and vulnerable members of society. To offer a more balanced representation of missionaries in historical literature, more research is needed that highlights their community engagement and partnerships with local people on the ground where health care actually took place.7,8 Thus, in this article, we challenge the imperialist narrative of medical missions to document the historical factors that led to shifts in mission work. We assert that missions— particularly those run by Catholic sister physicians, nurses, and midwives—have changed over the last half of the 20th century and that those changes have been beneficial to the expansion of community health in sub-Saharan Africa. This article illustrates these changes through the lens of the Medical Mission Sisters from Philadelphia, Pennsylvania, and their work in maternal care in Ghana. We have interviewed many of these Catholic sisters over the past 2 years, and their stories and testimonies have informed much our research. We have also used primary written sources from the sisters’ archives, such as brochures, teaching booklets, and photographs. So how exactly have Catholic missions changed over time? To understand these transformations, it is important to examine changes in Catholic theology as a result of revisions to Catholic Canon Law in 1936 and the declaration of the Second Vatican Council decree, Ad Gentes (On the Mission Activity of the Church), in 1965; and the Alma Ata Declaration in 1978 that called for international health agencies to increase their emphasis on primary care. CHANGES IN CATHOLIC THEOLOGY Revisions of Catholic Canon Law in 1936: Increase in nursing scope of practice Catholic sisters’ medical mission work in the area of maternal care was only possible
when revisions to Catholic Canon Law occurred in 1936. Canon Law refers to the rules and regulations of the Church that the hierarchical authorities make and enforce. Prior to that time, although there was no prohibition on the practice of nursing, sisters’ scope of practice was restricted in that they were not allowed to aid in childbirth. They were also forbidden to become midwives and surgeons. As consecrated virgins, the thinking was that sisters should not be caring for men or women in such intimate settings that involved the naked body. Anna Dengel, an Austrian physician and foundress of the Medical Mission Sisters, was instrumental in lifting the restrictions on medical practice and changing Canon Law. Dengel had trained as a medical doctor at University College Cork in Ireland and worked for some years in India before she founded the Medical Mission Sisters in 1925 in Washington, District of Columbia. While in India, Dengel identified a dire need for female medical professionals who could assist in the deliveries of Muslim women. Unable to be touched by male physicians because of religious beliefs, the Muslim women would refuse care and die during childbirth. Dengel envisioned that an order of medically trained Catholic sisters would be the perfect solution to this public health problem and could address the needs of Muslim women in India. Dengel’s vision was revolutionary but would only be possible if Catholic sisters could be allowed to aid in childbirth. She appealed to the Pope and was granted permission in 1925 to organize an order of medically trained sisters, which would become the first order of its kind that expanded the career possibilities for religious women and increased their scope of medical and nursing practice. The community of women was formally made a religious congregation in 1941 and called the Medical Mission Sisters. Dengel wrote extensively of her vision: the Medical Mission Sisters were to be “good Samaritans” who would minister to the ill and to those who fell victim to superstition; science, expert knowledge, and professionalism were essential. Even as they believed in
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Women, Religion, and Maternal Health Care in Ghana science, sisters also committed themselves to the religious ideal of imitating Christ the healer. This blended model of care became central to Catholic sisters’ global outreach.9 The Medical Mission Sisters took vows of poverty, chastity, and obedience, but they also trained as nurses, midwives, physicians, social workers, pharmacists, and other medical professionals. By 1980, there were 700 members from 18 different countries working in 5 continents and addressing the health care needs of women not only in India but also in 33 other countries all over the world.9,10 Ad Gentes (On the Mission Activity of the Church), 1965: Community engagement and partnership The Second Vatican Council, or Vatican II, which met from 1962 to 1965, was another historical event that altered the trajectory of Catholic mission work. It was a pivotal event for Catholics all over the world. Vatican II changed how Catholic religious orders viewed their vocations and the Church itself and produced a paradigmatic shift for Catholic health care all over the world as more leadership roles were opened to the laity. Aggiornamento, or adaptation to meet the needs of the times, was one of the key terms used during the council. Missions specifically underwent a major change under the council’s Ad Gentes decree, which emphasized a greater appreciation of other cultures and solidarity with the local people. In line with Vatican II’s theological emphasis, sisters aligned themselves with the poor and the most vulnerable, who they considered the “people of God.”11 Ad Gentes asserted that mission was the very essence of the Catholic Church: “The pilgrim Church is missionary by her very nature, since it is from the mission of the Son and the mission of the Holy Spirit that she draws her origin, in accordance with the decree of God the Father.”11 As Stephen Bevans asserts; this was new. Mission was not something only missionaries did—the entire Church was mission. While commitment to evangelism was still important, more so was an obligation
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to social justice and a greater respect for all religions and cultures.11,12 In their mission work, sisters crossed geographic and spiritual boundaries by working with other cultures and having knowledge of those cultures.12 As a result, there was an increased push for missions to engage with the community and create partnerships with the local people. In the 1970s and early 1980s, the Medical Mission Sisters specifically began working with shamans and traditional midwives or birth attendants (TBAs). Sisters acknowledged and valued traditional workers’ expertise with the local population, and they recognized that these workers could offer valuable resources and knowledge for the sisters’ community health initiatives. By 1985, influence and ideas in medical and nursing treatment flowed in both directions, from sisters to Ghanaians, and vice versa, often in quite unexpected ways. THE ALMA ATA DECLARATION, 1978: PRIMARY CARE EMPHASIS Finally, the Alma Ata Declaration in 197813 was influential in shifting medical mission work from a focus on acute care to primary care and community health initiatives. An emphasis on acute care had origins in the colonial period when British colonizers began developing medical infrastructures in African urban centers to service the health care needs of their settlers and military forces. For this purpose, Western medicine facilitated white settlers’ adaptability and survival in some of the extreme climates and conditions of Africa while also decreasing their susceptibility to tropical diseases. Access to these hospitals and other medical facilities, however, was often strictly reserved for the British. From 1920 to 1930, medical infrastructure in Ghana grew as the British colonial government doubled its annual medical expenditures and hospital beds increased 10-fold. The government also built 3 large government hospitals, including one at Kumasi. The Depression of the 1930s, however, affected government spending, and no hospital was built between 1930 and 1945. While a Unified
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Colonial Medical Service was established in 1934, excessive overcrowding occurred in the available public health facilities. Deterioration in sanitary standards also occurred.14 After 1945, European colonial rule over African countries was falling apart and Africans were mobilizing themselves to organize new governments. When the British left after Ghana gained independence in 1957, control of the medical facilities shifted to local and national leaders. But very little expansion of health care infrastructure by the Ghanaian government occurred beyond the urban regions where colonists had originally settled, particularly with regard to acute and tertiary care services. Stephen Addae asserts that it was the missionaries who “provided the ordinary Africans any modern medical care and treatment.”14(p24) Missions focused their efforts on expanding access to health care to the local Ghanaians by building hospitals in rural regions. During that time, urbanization had not blossomed to the extent that it has today, and the majority of Ghanaians were living in small rural communities. By 1978, however, the international community recognized that there was an overemphasis of mission work on acute and tertiary care, and they were missing a huge opportunity for impact if they did not address community health issues. To address the needs of Ghanaians and people all over the world, the World Health Organization (WHO) and UNICEF held an International Conference on Primary Health Care in 1978 in Kazakhstan, Soviet Union. The Alma Ata Declaration was a direct product of that meeting. The declaration acknowledged that acute and tertiary care facilities were important, but there were not enough efforts toward community health and primary care. It asserted that health was a human right and identified primary care as the solution for achieving health for all by the year 2000. Three key tenets included the call for rural services and clinics rather than the construction of urban hospitals; opposition to biomedical exclusivity, thereby enhancing the worth of community healers; and improving living
conditions to improve health. It is important to note here that the missionary experience in community care, both Protestant and Catholic, was an important influence for primary care internationally.13 While the Medical Mission Sisters were already including community health in their mission activities long before the advent of Alma Ata, this declaration was an affirmation of their work. CHANGES OVER TIME AS EXEMPLIFIED BY THE MEDICAL MISSION SISTERS’ WORK IN MATERNAL HEALTH After 1936, with greater independence to do the work they wanted to do and with changes in Catholic theology that increased an emphasis on enculturation with local communities, the Medical Mission Sisters were prepared when the Alma Ata Declaration called for an increased focus on primary care. The sisters’ work in Ghana began when 3 sisters came to the Gold Coast (Ghana) in 1948 at the request of Chief Nana Yiadom Boakye Awusu of Berekum and the local Catholic bishop. On April 26 of that year, the elders of the Traditional Council officially welcomed the nuns at the Council Hall, and 2 days later, the people of Berekum greeted them with gifts of sheep, yams, and eggs.15 Support from local rulers was essential as a prerequisite for entering a region. The sisters initially opened a dispensary for medical, maternal, and child health care and were not only granted properties for the development of hospitals and schools but also the personnel to construct the buildings. Berekum is situated in the eastern part of what is now Ghana, about 20 miles west of Sunyani, the regional capital of the Brong-Ahafo area. It is a rural area. The sisters eventually established Holy Family Hospital, and at the time of its opening, the only acute care health facility nearby was the government hospital at Sunyani. Initially, Dengel viewed her sisters’ nursing and medicine as a “branch of missionary work through which skilled . . . care is given to the sick and poor of mission countries, as a means of relieving their physical suffering
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Women, Religion, and Maternal Health Care in Ghana and bringing to them a knowledge and appreciation of our Faith.”9(p1) She and other missionaries demonized indigenous medical systems. In 1939, 2 Medical Mission Sisters wrote a booklet for students interested in the mission field. They constructed an image of a primitive “Other” living in a land of poverty and superstition under the evil influence of medicine men and witch doctors. Good will and devotion were insufficient to fight these evils; rather, it was necessary to “use the best of modern science.” By this, they could show “the great value of medicine in the work of evangelization.”16(n.p.) In the colonial period, rather than claiming imperial expansion, priests and sisters were most interested in their mission: they wanted more Catholics, who they could get through their networks of schools and medical facilities. Through these, they could spread the gospel, convert Africans to Catholicism, and demonstrate Christian healing.9 Sisters did not yet consider that their own attempts to change indigenous populations spiritually and medically might be problematic. As further evidence of earlier motives for hospital work, a Catholic bishop commented in 1949 about the importance of medical work for conversion, this time involving local nursing students: “Through them, large numbers of pagans come in contact with the Catholic Mission and hear for the first time the Name of the True God.”17(p71) For the reasons cited earlier in this article, however, the Medical Mission Sisters exemplified changes in their mission by increasing their emphasis on social justice and caring for all, including those in poor rural communities. By the 1990s, the sisters’ work in maternal care was especially notable for its focus on capacity building. In the process, the Medical Mission Sisters made specific contributions to maternal care in Ghana, with community health initiatives and partnerships with the local community shaping their work. To meet the needs of African women and prevent maternal deaths, the sisters built hospitals in rural Ghana; yet, their goal from the beginning was to educate and empower the
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local people to take ownership of their health care needs. Sisters started nursing schools and other training programs that would prepare the local Ghanaians to become medical and nursing staff and eventually take over the hospital. As one sister noted, “We do not leave until our job is done . . . until we can hand over the nursing school, hospital, or whatever it may be to the local community” (Sister Rose Kershbaumer, in an interview with the authors, May 10, 2012). Indeed, the sisters went to Ghana with the intention of assisting in capacity building rather than sustaining their own control. This strayed from any imperialist approach of their predecessors and decreased the Ghanaians’ dependency on Western resources. By 1988, Holy Family Hospital had an all Ghanaian staff, including the hospital administrator, matron, director of nursing services, nursing instructors or tutors, and head of midwifery training.15 Although the sisters had already begun primary care, they increased their emphasis after the Alma Ata Declaration, while not abandoning acute care. Reinforcing Sister Rose’s statement that the sisters had been active in preventive work before the 1978 Alma Ata Declaration, one sister recalled, When I went back [to Ghana] in ‘79, we really were on the cutting edge of that whole thing. We had one of our sister doctors who had studied public health and maternal child health and we already had maternal, antenatal clinics and well-baby clinics working, going along in the hospital, and they did outpatient care too. (Sister Margaret Moran, in an interview with the authors, February 17, 2012)
The sister continued, So Alma Alta came along and we had three goals. One was to provide quality, appropriate level of medical care, including surgical, without the specialties, the general surgery. Two was the midwifery and nursing education, and three was to be involved in primary health care. So we developed a job title called Primary Health Care Field Worker, which was what I did.
The sisters also carried out frequent “treks,” which were daylong clinics conducted in remote villages to promote antenatal care (Sister
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Margaret Moran, in an interview with the authors, February 17, 2012). Blending their religious beliefs and medicine, the sisters also focused on holistic healing, which was often accepted by the Ghanaians. The majority of Ghanaians were reported to be Christian at that time, with estimates being around 70%. Some women enjoyed the fact that Catholic sisters attended to their spiritual needs and viewed it as harmonious with their own (Sister Nkiruka Okafor, in an interview with the authors, August 30, 2012). Traditional Ghanaian medicine regards spirituality as an important aspect of the healing process, similar to the Catholic sisters’ own beliefs about spirituality and healing. Other Africans exercised their agency and simply resisted the sisters’ care altogether or consulted them purely for the biomedical aspect of their practice (Sister Mary Nesta, in an interview with the authors, August 30, 2012). One of the sisters who practiced in Ghana as a physician noted that the mothers would come to her already having self-diagnosed their children. Mothers carried their babies on their backs until the age of 2, and the sisterphysician admitted that the mothers knew their children better than she ever would and were merely looking for medication rather than expertise (Sister Jane Gates, in an interview with the authors, March 17, 2012). Other oral histories with the sisters revealed that they worked closely with the local Ghanaians and traditional healers in community health. In one testimony, a sister recalled receiving a position paper resulting from the Alma Ata conference, but it did not have any specific guidelines for implementation. Instead of developing the guidelines herself, she used the relationships she developed with people in the community to assess the community’s needs and determine how the people wanted to approach implementation (Sister Rose Kershbaumer, in an interview with the authors, May 10, 2012). The sisters also recognized the expertise of traditional healers and consulted with them for psychiatric cases and orthopedic injuries. In the same regard, TBAs sometimes sent complicated birth cases to the
hospital through a self-devised referral service. As important, Ghanaian staff at Holy Family Hospital were key actors in training indigenous healers and TBAs in nutrition and other aspects of primary care. This involved a high degree of community cooperation.18 DISCUSSION In 1987, the World Bank, in collaboration with the WHO, the United Nations, and other agencies, sponsored the Safe Motherhood Conference in Nairobi, Kenya, which was instrumental in gaining international awareness for the global issue of maternal mortality. Maternal deaths worldwide had risen to 600 000 in that year alone, 60% of which occurred in sub-Saharan Africa. On the basis of the assumption that these deaths could be prevented, the Safe Motherhood Initiative determined that skilled attendance at birth was the most effective way to reduce maternal mortality rates.19,20 They hoped to reduce maternal deaths by 75% and to achieve universal access to reproductive health by 2015, which later became the Millennium Development Goal 5.19 From the late 1980s to the early 1990s, agencies increased attention and funding to the training of TBAs, which was believed at the time to be the solution for reducing maternal mortality in Africa. A report released by the WHO 20 years later, however, tracked trends in maternal mortality from 1990 to 2008. Although the report did show a 34% decrease to 358 000 maternal deaths worldwide, there was insufficient progress made in the sub-Saharan region.20 The focus of training of TBAs in Africa had proved ineffective. It was at this time that TBAs became the scapegoats for maternal mortality and were blamed for being illiterate and unable to be trained. But in actuality, the solution to solving maternal mortality was beyond the scope of TBA practice and involved extenuating social and economic circumstances that were out of their control. The major causes of maternal death were severe bleeding, infection leading to sepsis, eclampsia, and obstructed labor, which required emergency obstetric care by midwives
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Women, Religion, and Maternal Health Care in Ghana and doctors. Poor nutrition and lack of access to medical facilities were also contributing factors of maternal death. To meet these needs, the Medical Mission Sisters took a more comprehensive approach that addressed both community health concerns and access to emergency care. Instead of simply training TBAs, the Medical Mission Sisters included them in their community work through partnerships and acknowledged that their knowledge and trust with the women were valuable and they were to be respected. They also built hospitals and nursing schools to expand local capacity that could address obstetric emergencies. Furthermore, local treks in the community to provide antenatal care and children’s clinics served as an extension of their hospital by providing access to primary care services. With their emphasis on capacity building, primary care, and partnerships, the Medical Mission Sisters serve as an example of Catholic missionaries whose strategies in addressing maternal care in Ghana may offer solutions to maternal mortality in the future. Although the Safe Motherhood Initiative was instrumental in raising international collaborative action against maternal mortality, missions had been at the forefront of providing localized efforts against maternal mortality in the decades prior.21 In 2007, the WHO estimated that faith-based organizations (FBOs), such as medical missions, provided between 30% and 70% of health care in various regions of Africa. Anthropologist James Ferguson argues that Christian missions “are arguably more important today in Africa than ever.”22 Currently, the African continent is the world’s second most vocation-rich continent in the world, surpassed only by Asia. More Catholic health care facilities are there in Africa than in North and Central America combined.23
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When it is noted that some of these Catholic hospitals and clinics are very often providing the only medical services and training schools in the area, the importance of religious health care institutions becomes even clearer. However, there is very little recognition or documentation of the contributions that FBOs have made in the training of health care professionals, especially in sub-Saharan Africa. Faith-based organizations may serve as an untapped resource for gaining progress toward Millennium Development Goal 5 in subSaharan Africa.24 Debates persist over gendered networks and how women’s groups worked within and also challenged barriers created by decolonization and dictatorships. Feminist scholarship asserts that colonial nurses’ intervention in indigenous women’s reproductive lives resulted in a loss of local knowledge and autonomy for women in their communities.25 Other scholars see this work as meeting the needs of women at a time when health policies for them were woefully inadequate.26 The missionaries themselves viewed their work for women and children as a priority because of unusually high infant and maternal deaths. Sisters measured their outcomes in terms of villagers’ reports, namely, as one sister reported, “no more women are dying in labor” (Sister Rose Kershbaumer, in an interview with the authors, May 10, 2012). In all of these activities, the sisters viewed their work as a move toward justice for the poor. Rather than concentrating their resources in large hospitals alone, they went to smaller rural communities and lived and worked among the residents. As they moved closer to the people and reoriented their services to better serve the poor, the sisters and local healers together played key roles in improving the health of families in local communities.
REFERENCES 1. Comaroff JL, Comaroff J. Of Revelation and Revolution, Vol I: Christianity, Colonialism, and Consciousness in South Africa. Chicago, IL: University of Chicago Press; 1991.
2. Comaroff JL, Comaroff J. Of Revelation and Revolution, Vol 2: The Dialectics of Modernity on a South African Frontier. Chicago, IL: University of Chicago Press; 1997.
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3. Hutchison WR, Christensen T, eds. Missionary Ideologies in the Imperialist Era: 18801920. Aarhus, Denmark: Christensens Bogtrykkeri; 1982. 4. Porter A. Religion Versus Empire? British Protestant Missionaries and Overseas Expansion, 1700-1914. Manchester, England: Manchester University Press; 2004. 5. Ward K. Christianity, Colonialism and Missions. In:McLeod H, ed. Cambridge History of Christianity, Vol 9, World Christianities, 1914-2000. Cambridge, England: Cambridge University Press; 2006:71-88. 6. Vaughan M. Curing Their Ills: Colonial Power and African Illness. Stanford, CA: Stanford University Press; 1991. 7. Robert DL. Christian Mission: How Christianity Became a World Religion. West Sussex, England: Wiley-Blackwell; 2009. 8. Robert DL. Converting Colonialism: Visions and Realities in Mission History, 1706-1914. Grand Rapids, MI: Wm B Eerdmans Publishing Co; 2008. 9. Dengel A. Mission for Samaritans. Milwaukee, WI: Bruce Publishing Co; 1945. 10. Hogan EM. The Irish Missionary Movement: A Historical Survey, 1830-1980. Dublin, Ireland: Gill & Macmillan; 1990. 11. The Vatican. Ad Gentes. http://www.vatican. va/archive/hist councils/ii vatican council/ documents/vat-ii decree 19651207 ad-gentes en. html. Published December 7, 1965. Accessed September 15, 2013. 12. Bevans S. Church Teaching On Mission: Ad Gentes, Evangelii Nuntiandi, Redemptoris Missio and Dialogue and Proclamation. http://www.maryknoll vocations.com/mission.pdf. Accessed September 13, 2013. 13. Cueto M. The origins of primary health care and selective primary health care. Am J Public Health. 2004;94(11):1864-1874. 14. Addae S. The Evolution of Modern Medicine in a Developing Country: Ghana 1880-1960. Edinburgh, England: Durham Academic Press; 1997. 15. Medical Mission Sisters. Holy Family Hospital Berekum, 1948-1988, 40th Anniversary Brochure. Fox Chase, Philadelphia: Archives of the Medical Mission Sisters (hereafter cited as MMS).
16. Fliegler ML, Patrick MF. Medicine in the Service of Foreign Missions. Cincinnati, OH: National Center, Catholic Students’ Mission Crusade; 1939. Located at: MMS. 17. Missionary Sisters of Our Lady of the Holy Rosary. Silver Sheaves: A Record of Twenty-five Years at Home and in Africa. Killeshandra, County Cavan, Ireland: Missionary Sisters of Our Lady of the Holy Rosary; 1949. Located at: the Bodleian Library, Oxford, England. 18. Warren DM, Bova GS, Tregoning MA, Kliewer M. Ghanaian national policy toward indigenous healers. Soc Sci Med. 1982;16:1873-1881. 19. United Nations Population Fund. Safe motherhood. http://web.unfpa.org/monitoring/pdf/n-issue10. pdf. Published in Issue 10, January 1999. Accessed September 15, 2013. 20. Wilmoth J, Mathers C, Say L, Mills S. Maternal deaths drop by one-third from 1990 to 2008: a United Nations analysis. Bull World Health Organ. 2010;88(10). http://www.scielosp.org/ scielo.php?pid=S004296862010001000002&script= sci arttext&tlng=pt. Accessed September 21, 2013. 21. Pearl E, Chand S, Hafner C. Training health workers in Africa: documenting faith-based organizations’ contributions. http://www.capacityplus.org/ files/resources/projectTechBrief 17.pdf. Published 2009. Accessed September 30, 2013. 22. Ferguson J. Global Shadows: Africa in the Neoliberal World Order. Durham, NC: Duke University Press; 2006. 23. Amid explosive church growth, African bishops meet. http://www.catholicculture.org/news/ headlines/index.cfm?storyid=7022. Published July 28, 2010. Accessed January 15, 2011. 24. Widmer M, Betran AP, Merialdi M, Requejo J, Karpf T. The role of faith-based organizations in maternal and newborn health care in Africa. Int J Gynecol Obstet. 2011; 114: 218-222. 25. Nestel S. (Ad)ministering angels: colonial nursing and the extension of empire in Africa. J Med Humanit. 1998;19(4):257-277. 26. Fitzgerald R. Rescue and redemption: the rise of female medical missions in colonial India during the late nineteenth and early twentieth centuries. In:Rafferty AM, Robinson J, Elkan R, eds. Nursing History and the Politics of Welfare. New York, NY: Routledge; 1997:64-79.
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Women, Religion, and Maternal Health Care in Ghana, 1945-2000 Lauren Johnson, BSN; Barbra Mann Wall, PhD, RN, FAAN This article documents the historical factors that led to shifts in mission work toward a greater emphasis on community health for the poor and most vulnerable of society in sub-Saharan Africa after 1945. Using the example of the Medical Mission Sisters from Philadelphia, Pennsylvania, and their work in Ghana, we challenge the conventional narrative of medical missions as agents of imperialism. We assert that missions—particularly those run by Catholic sister physicians, nurses, and midwives—have changed over time and that those changes have been beneficial to the expansion of community health, particularly in the area of improvement of maternal care. Key words: Alma Ata, mission, primary care, sub-Saharan Africa
I
N DESCRIBING her midwifery work in rural Ghana, Sister Rose Kershbaumer, a Medical Mission Sister, stated,
We started out hospital based . . . . Very early in Ghana, we started what we called “treks.” And we’d go out to the village for antenatal care, for “under five” clinics, so we have always been outside the hospital . . . . You need a place for acute care . . . . You have to send in your referrals. And you have to identify problems. But we have always been strong on community. (Sister Rose Kershbaumer, in an interview with the authors, May 10, 2012)
Sister Rose’s comment emphasizes community health in the mission work of Catholic sisters. Yet, their contributions have been overshadowed in historical literature by a focus on Author Affiliation: School of Nursing, University of Pennsylvania, Philadelphia. Funding for this research was provided by the University of Pennsylvania Urban Research Institute Award, the University of Pennsylvania School of Nursing’s F(our)ULD Undergraduate Research Award, and the University of Pennsylvania URF and Vagelos grants. The authors declare no conflict of interest. Correspondence: Lauren Johnson, BSN, School of Nursing, University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA 19104 ([email protected]). DOI: 10.1097/FCH.0000000000000032
the colonial era and interpretations of hegemonic, imperialist themes. Conventional accounts of the history of nursing and health care in sub-Saharan Africa have indicted Christianity and biomedicine as tools of European colonial expansion.1-5 Medicine was interpreted as a means to evangelize and attain willing converts. According to this interpretation, missionaries viewed the “sickbed” as the most receptive time in a person’s life to surrender to the will of God. Megan Vaughan’s Curing Their Ills is especially insightful for its analysis of Protestant medical missionary discourse, primarily British, during the colonial era and its representations of African culture and patients. In her analysis, missionary rhetoric revealed that medical mission work “was part of a program of social and moral engineering through which ‘Africa’ would be saved.”6(p74) While Vaughan is sensitive to the problems of using missionary language as evidence for actual encounters on the ground, her work and others have held lasting influence among both popular and academic audiences. This depiction of missionaries as agents of imperialism has largely been left unchallenged, which perpetuates the idea that missions have remained imperialist since their beginnings. While evangelism was the primary focus of missionaries in the precolonial and 223
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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colonial periods, their focus has shifted over the last half of the 20th century to one of service and social justice, including greater concern for the poor and vulnerable members of society. To offer a more balanced representation of missionaries in historical literature, more research is needed that highlights their community engagement and partnerships with local people on the ground where health care actually took place.7,8 Thus, in this article, we challenge the imperialist narrative of medical missions to document the historical factors that led to shifts in mission work. We assert that missions— particularly those run by Catholic sister physicians, nurses, and midwives—have changed over the last half of the 20th century and that those changes have been beneficial to the expansion of community health in sub-Saharan Africa. This article illustrates these changes through the lens of the Medical Mission Sisters from Philadelphia, Pennsylvania, and their work in maternal care in Ghana. We have interviewed many of these Catholic sisters over the past 2 years, and their stories and testimonies have informed much our research. We have also used primary written sources from the sisters’ archives, such as brochures, teaching booklets, and photographs. So how exactly have Catholic missions changed over time? To understand these transformations, it is important to examine changes in Catholic theology as a result of revisions to Catholic Canon Law in 1936 and the declaration of the Second Vatican Council decree, Ad Gentes (On the Mission Activity of the Church), in 1965; and the Alma Ata Declaration in 1978 that called for international health agencies to increase their emphasis on primary care. CHANGES IN CATHOLIC THEOLOGY Revisions of Catholic Canon Law in 1936: Increase in nursing scope of practice Catholic sisters’ medical mission work in the area of maternal care was only possible
when revisions to Catholic Canon Law occurred in 1936. Canon Law refers to the rules and regulations of the Church that the hierarchical authorities make and enforce. Prior to that time, although there was no prohibition on the practice of nursing, sisters’ scope of practice was restricted in that they were not allowed to aid in childbirth. They were also forbidden to become midwives and surgeons. As consecrated virgins, the thinking was that sisters should not be caring for men or women in such intimate settings that involved the naked body. Anna Dengel, an Austrian physician and foundress of the Medical Mission Sisters, was instrumental in lifting the restrictions on medical practice and changing Canon Law. Dengel had trained as a medical doctor at University College Cork in Ireland and worked for some years in India before she founded the Medical Mission Sisters in 1925 in Washington, District of Columbia. While in India, Dengel identified a dire need for female medical professionals who could assist in the deliveries of Muslim women. Unable to be touched by male physicians because of religious beliefs, the Muslim women would refuse care and die during childbirth. Dengel envisioned that an order of medically trained Catholic sisters would be the perfect solution to this public health problem and could address the needs of Muslim women in India. Dengel’s vision was revolutionary but would only be possible if Catholic sisters could be allowed to aid in childbirth. She appealed to the Pope and was granted permission in 1925 to organize an order of medically trained sisters, which would become the first order of its kind that expanded the career possibilities for religious women and increased their scope of medical and nursing practice. The community of women was formally made a religious congregation in 1941 and called the Medical Mission Sisters. Dengel wrote extensively of her vision: the Medical Mission Sisters were to be “good Samaritans” who would minister to the ill and to those who fell victim to superstition; science, expert knowledge, and professionalism were essential. Even as they believed in
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Women, Religion, and Maternal Health Care in Ghana science, sisters also committed themselves to the religious ideal of imitating Christ the healer. This blended model of care became central to Catholic sisters’ global outreach.9 The Medical Mission Sisters took vows of poverty, chastity, and obedience, but they also trained as nurses, midwives, physicians, social workers, pharmacists, and other medical professionals. By 1980, there were 700 members from 18 different countries working in 5 continents and addressing the health care needs of women not only in India but also in 33 other countries all over the world.9,10 Ad Gentes (On the Mission Activity of the Church), 1965: Community engagement and partnership The Second Vatican Council, or Vatican II, which met from 1962 to 1965, was another historical event that altered the trajectory of Catholic mission work. It was a pivotal event for Catholics all over the world. Vatican II changed how Catholic religious orders viewed their vocations and the Church itself and produced a paradigmatic shift for Catholic health care all over the world as more leadership roles were opened to the laity. Aggiornamento, or adaptation to meet the needs of the times, was one of the key terms used during the council. Missions specifically underwent a major change under the council’s Ad Gentes decree, which emphasized a greater appreciation of other cultures and solidarity with the local people. In line with Vatican II’s theological emphasis, sisters aligned themselves with the poor and the most vulnerable, who they considered the “people of God.”11 Ad Gentes asserted that mission was the very essence of the Catholic Church: “The pilgrim Church is missionary by her very nature, since it is from the mission of the Son and the mission of the Holy Spirit that she draws her origin, in accordance with the decree of God the Father.”11 As Stephen Bevans asserts; this was new. Mission was not something only missionaries did—the entire Church was mission. While commitment to evangelism was still important, more so was an obligation
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to social justice and a greater respect for all religions and cultures.11,12 In their mission work, sisters crossed geographic and spiritual boundaries by working with other cultures and having knowledge of those cultures.12 As a result, there was an increased push for missions to engage with the community and create partnerships with the local people. In the 1970s and early 1980s, the Medical Mission Sisters specifically began working with shamans and traditional midwives or birth attendants (TBAs). Sisters acknowledged and valued traditional workers’ expertise with the local population, and they recognized that these workers could offer valuable resources and knowledge for the sisters’ community health initiatives. By 1985, influence and ideas in medical and nursing treatment flowed in both directions, from sisters to Ghanaians, and vice versa, often in quite unexpected ways. THE ALMA ATA DECLARATION, 1978: PRIMARY CARE EMPHASIS Finally, the Alma Ata Declaration in 197813 was influential in shifting medical mission work from a focus on acute care to primary care and community health initiatives. An emphasis on acute care had origins in the colonial period when British colonizers began developing medical infrastructures in African urban centers to service the health care needs of their settlers and military forces. For this purpose, Western medicine facilitated white settlers’ adaptability and survival in some of the extreme climates and conditions of Africa while also decreasing their susceptibility to tropical diseases. Access to these hospitals and other medical facilities, however, was often strictly reserved for the British. From 1920 to 1930, medical infrastructure in Ghana grew as the British colonial government doubled its annual medical expenditures and hospital beds increased 10-fold. The government also built 3 large government hospitals, including one at Kumasi. The Depression of the 1930s, however, affected government spending, and no hospital was built between 1930 and 1945. While a Unified
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Colonial Medical Service was established in 1934, excessive overcrowding occurred in the available public health facilities. Deterioration in sanitary standards also occurred.14 After 1945, European colonial rule over African countries was falling apart and Africans were mobilizing themselves to organize new governments. When the British left after Ghana gained independence in 1957, control of the medical facilities shifted to local and national leaders. But very little expansion of health care infrastructure by the Ghanaian government occurred beyond the urban regions where colonists had originally settled, particularly with regard to acute and tertiary care services. Stephen Addae asserts that it was the missionaries who “provided the ordinary Africans any modern medical care and treatment.”14(p24) Missions focused their efforts on expanding access to health care to the local Ghanaians by building hospitals in rural regions. During that time, urbanization had not blossomed to the extent that it has today, and the majority of Ghanaians were living in small rural communities. By 1978, however, the international community recognized that there was an overemphasis of mission work on acute and tertiary care, and they were missing a huge opportunity for impact if they did not address community health issues. To address the needs of Ghanaians and people all over the world, the World Health Organization (WHO) and UNICEF held an International Conference on Primary Health Care in 1978 in Kazakhstan, Soviet Union. The Alma Ata Declaration was a direct product of that meeting. The declaration acknowledged that acute and tertiary care facilities were important, but there were not enough efforts toward community health and primary care. It asserted that health was a human right and identified primary care as the solution for achieving health for all by the year 2000. Three key tenets included the call for rural services and clinics rather than the construction of urban hospitals; opposition to biomedical exclusivity, thereby enhancing the worth of community healers; and improving living
conditions to improve health. It is important to note here that the missionary experience in community care, both Protestant and Catholic, was an important influence for primary care internationally.13 While the Medical Mission Sisters were already including community health in their mission activities long before the advent of Alma Ata, this declaration was an affirmation of their work. CHANGES OVER TIME AS EXEMPLIFIED BY THE MEDICAL MISSION SISTERS’ WORK IN MATERNAL HEALTH After 1936, with greater independence to do the work they wanted to do and with changes in Catholic theology that increased an emphasis on enculturation with local communities, the Medical Mission Sisters were prepared when the Alma Ata Declaration called for an increased focus on primary care. The sisters’ work in Ghana began when 3 sisters came to the Gold Coast (Ghana) in 1948 at the request of Chief Nana Yiadom Boakye Awusu of Berekum and the local Catholic bishop. On April 26 of that year, the elders of the Traditional Council officially welcomed the nuns at the Council Hall, and 2 days later, the people of Berekum greeted them with gifts of sheep, yams, and eggs.15 Support from local rulers was essential as a prerequisite for entering a region. The sisters initially opened a dispensary for medical, maternal, and child health care and were not only granted properties for the development of hospitals and schools but also the personnel to construct the buildings. Berekum is situated in the eastern part of what is now Ghana, about 20 miles west of Sunyani, the regional capital of the Brong-Ahafo area. It is a rural area. The sisters eventually established Holy Family Hospital, and at the time of its opening, the only acute care health facility nearby was the government hospital at Sunyani. Initially, Dengel viewed her sisters’ nursing and medicine as a “branch of missionary work through which skilled . . . care is given to the sick and poor of mission countries, as a means of relieving their physical suffering
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Women, Religion, and Maternal Health Care in Ghana and bringing to them a knowledge and appreciation of our Faith.”9(p1) She and other missionaries demonized indigenous medical systems. In 1939, 2 Medical Mission Sisters wrote a booklet for students interested in the mission field. They constructed an image of a primitive “Other” living in a land of poverty and superstition under the evil influence of medicine men and witch doctors. Good will and devotion were insufficient to fight these evils; rather, it was necessary to “use the best of modern science.” By this, they could show “the great value of medicine in the work of evangelization.”16(n.p.) In the colonial period, rather than claiming imperial expansion, priests and sisters were most interested in their mission: they wanted more Catholics, who they could get through their networks of schools and medical facilities. Through these, they could spread the gospel, convert Africans to Catholicism, and demonstrate Christian healing.9 Sisters did not yet consider that their own attempts to change indigenous populations spiritually and medically might be problematic. As further evidence of earlier motives for hospital work, a Catholic bishop commented in 1949 about the importance of medical work for conversion, this time involving local nursing students: “Through them, large numbers of pagans come in contact with the Catholic Mission and hear for the first time the Name of the True God.”17(p71) For the reasons cited earlier in this article, however, the Medical Mission Sisters exemplified changes in their mission by increasing their emphasis on social justice and caring for all, including those in poor rural communities. By the 1990s, the sisters’ work in maternal care was especially notable for its focus on capacity building. In the process, the Medical Mission Sisters made specific contributions to maternal care in Ghana, with community health initiatives and partnerships with the local community shaping their work. To meet the needs of African women and prevent maternal deaths, the sisters built hospitals in rural Ghana; yet, their goal from the beginning was to educate and empower the
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local people to take ownership of their health care needs. Sisters started nursing schools and other training programs that would prepare the local Ghanaians to become medical and nursing staff and eventually take over the hospital. As one sister noted, “We do not leave until our job is done . . . until we can hand over the nursing school, hospital, or whatever it may be to the local community” (Sister Rose Kershbaumer, in an interview with the authors, May 10, 2012). Indeed, the sisters went to Ghana with the intention of assisting in capacity building rather than sustaining their own control. This strayed from any imperialist approach of their predecessors and decreased the Ghanaians’ dependency on Western resources. By 1988, Holy Family Hospital had an all Ghanaian staff, including the hospital administrator, matron, director of nursing services, nursing instructors or tutors, and head of midwifery training.15 Although the sisters had already begun primary care, they increased their emphasis after the Alma Ata Declaration, while not abandoning acute care. Reinforcing Sister Rose’s statement that the sisters had been active in preventive work before the 1978 Alma Ata Declaration, one sister recalled, When I went back [to Ghana] in ‘79, we really were on the cutting edge of that whole thing. We had one of our sister doctors who had studied public health and maternal child health and we already had maternal, antenatal clinics and well-baby clinics working, going along in the hospital, and they did outpatient care too. (Sister Margaret Moran, in an interview with the authors, February 17, 2012)
The sister continued, So Alma Alta came along and we had three goals. One was to provide quality, appropriate level of medical care, including surgical, without the specialties, the general surgery. Two was the midwifery and nursing education, and three was to be involved in primary health care. So we developed a job title called Primary Health Care Field Worker, which was what I did.
The sisters also carried out frequent “treks,” which were daylong clinics conducted in remote villages to promote antenatal care (Sister
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Margaret Moran, in an interview with the authors, February 17, 2012). Blending their religious beliefs and medicine, the sisters also focused on holistic healing, which was often accepted by the Ghanaians. The majority of Ghanaians were reported to be Christian at that time, with estimates being around 70%. Some women enjoyed the fact that Catholic sisters attended to their spiritual needs and viewed it as harmonious with their own (Sister Nkiruka Okafor, in an interview with the authors, August 30, 2012). Traditional Ghanaian medicine regards spirituality as an important aspect of the healing process, similar to the Catholic sisters’ own beliefs about spirituality and healing. Other Africans exercised their agency and simply resisted the sisters’ care altogether or consulted them purely for the biomedical aspect of their practice (Sister Mary Nesta, in an interview with the authors, August 30, 2012). One of the sisters who practiced in Ghana as a physician noted that the mothers would come to her already having self-diagnosed their children. Mothers carried their babies on their backs until the age of 2, and the sisterphysician admitted that the mothers knew their children better than she ever would and were merely looking for medication rather than expertise (Sister Jane Gates, in an interview with the authors, March 17, 2012). Other oral histories with the sisters revealed that they worked closely with the local Ghanaians and traditional healers in community health. In one testimony, a sister recalled receiving a position paper resulting from the Alma Ata conference, but it did not have any specific guidelines for implementation. Instead of developing the guidelines herself, she used the relationships she developed with people in the community to assess the community’s needs and determine how the people wanted to approach implementation (Sister Rose Kershbaumer, in an interview with the authors, May 10, 2012). The sisters also recognized the expertise of traditional healers and consulted with them for psychiatric cases and orthopedic injuries. In the same regard, TBAs sometimes sent complicated birth cases to the
hospital through a self-devised referral service. As important, Ghanaian staff at Holy Family Hospital were key actors in training indigenous healers and TBAs in nutrition and other aspects of primary care. This involved a high degree of community cooperation.18 DISCUSSION In 1987, the World Bank, in collaboration with the WHO, the United Nations, and other agencies, sponsored the Safe Motherhood Conference in Nairobi, Kenya, which was instrumental in gaining international awareness for the global issue of maternal mortality. Maternal deaths worldwide had risen to 600 000 in that year alone, 60% of which occurred in sub-Saharan Africa. On the basis of the assumption that these deaths could be prevented, the Safe Motherhood Initiative determined that skilled attendance at birth was the most effective way to reduce maternal mortality rates.19,20 They hoped to reduce maternal deaths by 75% and to achieve universal access to reproductive health by 2015, which later became the Millennium Development Goal 5.19 From the late 1980s to the early 1990s, agencies increased attention and funding to the training of TBAs, which was believed at the time to be the solution for reducing maternal mortality in Africa. A report released by the WHO 20 years later, however, tracked trends in maternal mortality from 1990 to 2008. Although the report did show a 34% decrease to 358 000 maternal deaths worldwide, there was insufficient progress made in the sub-Saharan region.20 The focus of training of TBAs in Africa had proved ineffective. It was at this time that TBAs became the scapegoats for maternal mortality and were blamed for being illiterate and unable to be trained. But in actuality, the solution to solving maternal mortality was beyond the scope of TBA practice and involved extenuating social and economic circumstances that were out of their control. The major causes of maternal death were severe bleeding, infection leading to sepsis, eclampsia, and obstructed labor, which required emergency obstetric care by midwives
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Women, Religion, and Maternal Health Care in Ghana and doctors. Poor nutrition and lack of access to medical facilities were also contributing factors of maternal death. To meet these needs, the Medical Mission Sisters took a more comprehensive approach that addressed both community health concerns and access to emergency care. Instead of simply training TBAs, the Medical Mission Sisters included them in their community work through partnerships and acknowledged that their knowledge and trust with the women were valuable and they were to be respected. They also built hospitals and nursing schools to expand local capacity that could address obstetric emergencies. Furthermore, local treks in the community to provide antenatal care and children’s clinics served as an extension of their hospital by providing access to primary care services. With their emphasis on capacity building, primary care, and partnerships, the Medical Mission Sisters serve as an example of Catholic missionaries whose strategies in addressing maternal care in Ghana may offer solutions to maternal mortality in the future. Although the Safe Motherhood Initiative was instrumental in raising international collaborative action against maternal mortality, missions had been at the forefront of providing localized efforts against maternal mortality in the decades prior.21 In 2007, the WHO estimated that faith-based organizations (FBOs), such as medical missions, provided between 30% and 70% of health care in various regions of Africa. Anthropologist James Ferguson argues that Christian missions “are arguably more important today in Africa than ever.”22 Currently, the African continent is the world’s second most vocation-rich continent in the world, surpassed only by Asia. More Catholic health care facilities are there in Africa than in North and Central America combined.23
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When it is noted that some of these Catholic hospitals and clinics are very often providing the only medical services and training schools in the area, the importance of religious health care institutions becomes even clearer. However, there is very little recognition or documentation of the contributions that FBOs have made in the training of health care professionals, especially in sub-Saharan Africa. Faith-based organizations may serve as an untapped resource for gaining progress toward Millennium Development Goal 5 in subSaharan Africa.24 Debates persist over gendered networks and how women’s groups worked within and also challenged barriers created by decolonization and dictatorships. Feminist scholarship asserts that colonial nurses’ intervention in indigenous women’s reproductive lives resulted in a loss of local knowledge and autonomy for women in their communities.25 Other scholars see this work as meeting the needs of women at a time when health policies for them were woefully inadequate.26 The missionaries themselves viewed their work for women and children as a priority because of unusually high infant and maternal deaths. Sisters measured their outcomes in terms of villagers’ reports, namely, as one sister reported, “no more women are dying in labor” (Sister Rose Kershbaumer, in an interview with the authors, May 10, 2012). In all of these activities, the sisters viewed their work as a move toward justice for the poor. Rather than concentrating their resources in large hospitals alone, they went to smaller rural communities and lived and worked among the residents. As they moved closer to the people and reoriented their services to better serve the poor, the sisters and local healers together played key roles in improving the health of families in local communities.
REFERENCES 1. Comaroff JL, Comaroff J. Of Revelation and Revolution, Vol I: Christianity, Colonialism, and Consciousness in South Africa. Chicago, IL: University of Chicago Press; 1991.
2. Comaroff JL, Comaroff J. Of Revelation and Revolution, Vol 2: The Dialectics of Modernity on a South African Frontier. Chicago, IL: University of Chicago Press; 1997.
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3. Hutchison WR, Christensen T, eds. Missionary Ideologies in the Imperialist Era: 18801920. Aarhus, Denmark: Christensens Bogtrykkeri; 1982. 4. Porter A. Religion Versus Empire? British Protestant Missionaries and Overseas Expansion, 1700-1914. Manchester, England: Manchester University Press; 2004. 5. Ward K. Christianity, Colonialism and Missions. In:McLeod H, ed. Cambridge History of Christianity, Vol 9, World Christianities, 1914-2000. Cambridge, England: Cambridge University Press; 2006:71-88. 6. Vaughan M. Curing Their Ills: Colonial Power and African Illness. Stanford, CA: Stanford University Press; 1991. 7. Robert DL. Christian Mission: How Christianity Became a World Religion. West Sussex, England: Wiley-Blackwell; 2009. 8. Robert DL. Converting Colonialism: Visions and Realities in Mission History, 1706-1914. Grand Rapids, MI: Wm B Eerdmans Publishing Co; 2008. 9. Dengel A. Mission for Samaritans. Milwaukee, WI: Bruce Publishing Co; 1945. 10. Hogan EM. The Irish Missionary Movement: A Historical Survey, 1830-1980. Dublin, Ireland: Gill & Macmillan; 1990. 11. The Vatican. Ad Gentes. http://www.vatican. va/archive/hist councils/ii vatican council/ documents/vat-ii decree 19651207 ad-gentes en. html. Published December 7, 1965. Accessed September 15, 2013. 12. Bevans S. Church Teaching On Mission: Ad Gentes, Evangelii Nuntiandi, Redemptoris Missio and Dialogue and Proclamation. http://www.maryknoll vocations.com/mission.pdf. Accessed September 13, 2013. 13. Cueto M. The origins of primary health care and selective primary health care. Am J Public Health. 2004;94(11):1864-1874. 14. Addae S. The Evolution of Modern Medicine in a Developing Country: Ghana 1880-1960. Edinburgh, England: Durham Academic Press; 1997. 15. Medical Mission Sisters. Holy Family Hospital Berekum, 1948-1988, 40th Anniversary Brochure. Fox Chase, Philadelphia: Archives of the Medical Mission Sisters (hereafter cited as MMS).
16. Fliegler ML, Patrick MF. Medicine in the Service of Foreign Missions. Cincinnati, OH: National Center, Catholic Students’ Mission Crusade; 1939. Located at: MMS. 17. Missionary Sisters of Our Lady of the Holy Rosary. Silver Sheaves: A Record of Twenty-five Years at Home and in Africa. Killeshandra, County Cavan, Ireland: Missionary Sisters of Our Lady of the Holy Rosary; 1949. Located at: the Bodleian Library, Oxford, England. 18. Warren DM, Bova GS, Tregoning MA, Kliewer M. Ghanaian national policy toward indigenous healers. Soc Sci Med. 1982;16:1873-1881. 19. United Nations Population Fund. Safe motherhood. http://web.unfpa.org/monitoring/pdf/n-issue10. pdf. Published in Issue 10, January 1999. Accessed September 15, 2013. 20. Wilmoth J, Mathers C, Say L, Mills S. Maternal deaths drop by one-third from 1990 to 2008: a United Nations analysis. Bull World Health Organ. 2010;88(10). http://www.scielosp.org/ scielo.php?pid=S004296862010001000002&script= sci arttext&tlng=pt. Accessed September 21, 2013. 21. Pearl E, Chand S, Hafner C. Training health workers in Africa: documenting faith-based organizations’ contributions. http://www.capacityplus.org/ files/resources/projectTechBrief 17.pdf. Published 2009. Accessed September 30, 2013. 22. Ferguson J. Global Shadows: Africa in the Neoliberal World Order. Durham, NC: Duke University Press; 2006. 23. Amid explosive church growth, African bishops meet. http://www.catholicculture.org/news/ headlines/index.cfm?storyid=7022. Published July 28, 2010. Accessed January 15, 2011. 24. Widmer M, Betran AP, Merialdi M, Requejo J, Karpf T. The role of faith-based organizations in maternal and newborn health care in Africa. Int J Gynecol Obstet. 2011; 114: 218-222. 25. Nestel S. (Ad)ministering angels: colonial nursing and the extension of empire in Africa. J Med Humanit. 1998;19(4):257-277. 26. Fitzgerald R. Rescue and redemption: the rise of female medical missions in colonial India during the late nineteenth and early twentieth centuries. In:Rafferty AM, Robinson J, Elkan R, eds. Nursing History and the Politics of Welfare. New York, NY: Routledge; 1997:64-79.
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