Improving access to fresh food in Labrador

[Individual articles from the Winter 2017 issue of Intersections will be posted on this blog each week. The full issue can be found on MCC’s website.]

Labrador is much like the rest of Canada’s north. Indigenous peoples have hunted, fished and raised their families on these lands for generations. The land has suffered from the impacts of colonization, as have its people. Resource extraction has changed the face of the land. Rivers have been diverted, habitat has been lost, causing a shift in migratory patterns of the caribou, and increased levels of methylmercury continue to affect fish and sea life in the Mishtashipu, now officially called the Churchill River, more than 40 years after the construction of the first hydroelectric project. Depletion of the caribou herds has resulted in a complete hunting ban and the government also places restrictions on hunting migratory birds and fish. In Labrador, gaining access to fresh, healthy and culturally appropriate food is more and more difficult each year. Yet in face of these challenges indigenous communities mobilize to address food and nutrition needs.

“No more than one a week to eat from the river,” Innu elder, Elizabeth Penashue, told me as we sat next to the Mishtashipu and talked about the pollution in the river. Only one rusted sign outside the town of Happy Valley-Goose Bay warns people to limit consumption of fish caught in the river due to pollution. Penashue thinks there should be more warnings.

Access to quality, fresh food is a challenge in Labrador. Because of the area’s remoteness, shipping is expensive and can be slow. Walking into grocery stores in the winter and finding bare shelves is not unusual. Depending on the weather, that happens in the coastal communities throughout the summer, too. The cost of food is so high that people often eat cheaper, less nutritious and more processed foods just to help make ends meet.

The Community Food Hub, based in Happy Valley-Goose Bay, began in 2008 as a community project initiated by the local health authority and has grown into its own non-profit organization offering food education and programming in Labrador. An estimated 80% of the people served by the Community Food Hub identify as indigenous. The hub aims to address the community’s lack of healthy and culturally appropriate foods. MCC began a formal partnership with the Community Food Hub in 2012, when the food hub’s need for a part-time food security coordinator to complement and focus volunteer efforts became evident.

Currently the Community Food Hub facilitates several different programs. The hub’s children’s garden, in which an average of 190 students from two schools participate annually, is one of the hub’s most successful programs. The garden offers an opportunity for students in grades 4 and 5 to plant, care for, harvest and cook their own foods. Students have tried new vegetables, participated in the hard work of garden maintenance and cared for plants at home. Parents are also involved, and many have reported eating new foods and growing vegetables at home as a result of the program.

Community kitchens are another way of engaging the community. Focusing on low income families, the community kitchens provide opportunities for men and women to learn how to make low cost, healthy meals with others. Participants cook and eat together, after which they take the ingredients home to replicate the meal for their families. One of the surprising outcomes of this program is the online community-building it has facilitated. Members of the group share recipes, stories and pictures of their creations with one another, encouraging community.

The Community Food Hub works closely with the local agricultural association, ensuring that information about locally grown foods gets into the hands of shoppers. A community outdoor market program was started by the hub in 2013 in cooperation with the town of Happy Valley-Goose Bay and the agricultural association. Farmers were invited every Saturday between July and September to join the market. The market also showcased locally made goods and offered fair trade coffee. Workshops on food preservation and wild food gathering were presented, along with demonstrations and trainings to encourage local gardening. In 2015, the Community Outdoor Market ceased being a program of the hub and continues successfully under the guidance of community volunteers. The hub nevertheless remains engaged with the market, setting up healthy eating and living displays at the market each week.

Initially, the hub began a community freezer project, hoping to provide food from the land gathered by local volunteers, such as fish, wild game and berries, to people who unable to hunt and gather on their own. It started with some exciting donations, like moose and caribou meat. However, due to reduced hunting quotas and people needing to save their catch for their own consumption in the winter, food donations were limited and the project ended. A similar project run by the Nunatsiavut Government is still available for seniors and shut-ins when food is able to be harvested or donated for distribution.

The challenges of food security continue to increase. Today, another large infrastructure project, the Lower Churchill Hydroelectric (or Muskrat Falls) Dam, threatens the health of the waters and way of life for the people who live in central and eastern Labrador. All three indigenous groups in the area (the Nunatsiavut, NunatuKavut and Innu nations), have come together to demand either the clearing of vegetation in the new reservoir in order to reduce imminent methylmercury poisoning and perhaps even to stop the dam completely. While the Community Food Hub is not directly involved in protesting, it does organize educational events to raise awareness about the effects of methylmercury in the local food system.

Food security and nutrition challenges have no easy answer in the North. Increasing access to fresh, local food from community gardens, children’s gardens and farmers’ markets can generally happen only in July, August and September. Freezing and canning meat and produce can help bridge the gap, but the winter period when food cannot be locally produced is long. Freezing and canning food is also expensive compared to the alternative of buying processed food during the winter months. Long term solutions are needed, but, for now, the Community Food Hub offers a partial solution with its ongoing focus on education to help people learn how to make healthier choices with available resources.

Dianne Climenhage is an MCC representative for Newfoundland and Labrador, Canada

Learn more

 Council of Canadian Academies. Aboriginal Food Security in Northern Canada: An Assessment of the State of Knowledge. Ottawa: The Expert Panel on the State of Knowledge of Food Security in Northern Canada, Council of Canadian Academies, 2014.

Islam, Durdana and Fikret Berkes. “Indigenous Peoples’ Fisheries and Food Security: A Case from Northern Canada.” Food Security 8/4 (2016): 815-826.

Mother’s education as a predictor of child malnutrition in Nepal

[Individual articles from the Winter 2017 issue of Intersections will be posted on this blog each week. The full issue can be found on MCC’s website.]

Many people assume that household food insecurity is the main driving force behind childhood malnutrition and stunting. Simply put, the common assumption is that children are underweight because their families lack access to sufficient amounts of healthy food. However, a research study conducted by the Brethren in Community Welfare Society (BICWS) in the southern plains region of Nepal on the socioeconomic and cultural barriers to good nutrition found a more complicated picture. The study’s findings imply that while improving household food security may be necessary, it alone is insufficient to improve the nutritional status of children. The results suggest that malnutrition and stunting in this context are the result of interconnecting socioeconomic, educational and health-care factors. This study, alongside other research, suggests that an integrated strategy that improves the overall socioeconomic well-being of families, maternal education and knowledge of infant and young child feeding practices will be more effective and sustainable in improving the nutrition of children living in poverty.

BICWS operates as the service arm of the Brethren in Christ church conference in Nepal, based in the southeastern city of Biratnagar. Since many families in BICWS’ working area are rural landless households facing malnutrition, BICWS and MCC worked together to develop a food security project funded by MCC’s account at the Foods Resource Bank that included supplementary food for malnourished children as one of the project components, coupled with kitchen gardening and support for commercial vegetable and fish production.

Despite the short-term effectiveness of the supplementary food seen in many of the project participants, some malnourished children showed inadequate growth over the year of nutrition support, necessitating their re-enrollment for another year. BICWS conducted a research project in 2015 aimed at discovering the socioeconomic and cultural barriers and risk factors to healthy childhood development and recovery. The study involved in-depth interviews with participant households whose children did not recover from malnutrition and with participant households whose children recovered quickly.

The results of the study suggest that the initial hypothesis of food insecurity as the main driving force behind childhood malnutrition holds true, though only for the most extreme cases of households experiencing poverty and debt. It stands to reason that significant debt and related financial insecurity are major risk factors for childhood malnutrition. Families burdened by large debt payments have little or no financial security during periods of stressors, such as strikes, illnesses or disasters. In 2015 Nepal underwent a number of concurrent stressors, including a devastating earthquake, nationwide political unrest, strikes and an economic blockade from India. Health was one of the first things to deteriorate. Instead of a significant drop in caloric intake, affected families chose instead to drop many types of nutritious foods while keeping the amount of food consumed the same. Lack of dietary diversity contributes to malnutrition. While 80% of interviewed families stated that they normally had enough money for food, only 36% of families consumed the minimum daily nutrition requirements, showing a large gap between perceived food sufficiency and actual nutrient sufficiency.

For the non-extreme cases of malnutrition, however, the study discovered that the low level of mother’s educational attainment was connected with the incidence of malnutrition in children. That is, in families where the mother was more educated, children exhibited fast recovery. Other research projects in Nepal support this finding. This result suggests that women’s low educational attainment is linked to community malnutrition and that encouraging education is a strong potential long-term solution.

Nutrition-specific knowledge is also important. The study found that even some educated women lacked knowledge about health care, nutrition and sanitation. Lack of knowledge limited their application of good nutrition practice. However, BICWS found that educated women were more likely to take ownership of supplemental food received and to practice new nutrition skills than women with lower educational levels, despite the fact that both educated and uneducated women demonstrated low levels of nutritional knowledge before the project started. It makes sense that women’s education is likely to have an impact on family nutritional status, given the fact that in this community women normally serve as the center of the nuclear family and generally decide on and prepare daily meals. In response to these findings, BICWS has implemented a new strategy aimed at reaching three thousand households with nutritional education, equipping families (in particular women) with the knowledge of what nutritional strategies contribute to healthy development and overall well-being.

The BICWS research suggests that women’s education can be a cushion against stressors that lead to poverty and malnutrition. Women’s education and empowerment must be emphasized, especially as women in rural Nepal are often marginalized, with limited access to education and authority. Any long-term plan for community improvement should consider increasing women’s access to education as a key strategy. At the very minimum, this study suggests that nutritional education should be emphasized in any population suffering from malnutrition.

Derek Lee was on a SALT assignment with BICWS in 2015-16. Shemlal Hembrom is the program director of BICWS and General Secretary of BIC Nepal.

Learn more

Dhungana, Govinda Prasad. “Nutritional Status of Under 5 Children and Associated Factors of Kunchha Village Development Committee.” Journal of Chitwan Medical College 3/4 (January 2014): 38–42.

Osei, Akoto, Pooja Pandey, David Spiro, Jennifer Nielson, Ram Shrestha, Zaman Talukder, Victoria Quinn and Nancy Haselow “Household Food Insecurity and Nutritional Status of Children Aged 6 to 23 Months in Kailali District of Nepal.” Food and Nutrition Bulletin 31/4 (December 2010): 483–94.

Singh, G.C. Pramood, Manju Nair, Ruth B. Gruibesic and Frederick Connell. “Factors Associated with Underweight and Stunting among Children in Rural Terai of Eastern Nepal.” Asia-Pacific Journal of Public Health/Asia-Pacific Academic Consortium for Public Health 21/2 (April 2009): 144–52.

Addressing cultural barriers to nutrition in Nepal

[Individual articles from the Winter 2017 issue of Intersections will be posted on this blog each week. The full issue can be found on MCC’s website.]

In the Nepali context, household access to sufficient food does not ensure that all household members are well-nourished. Cultural beliefs about food consumption can lead to low nutritional status, particularly for highly-sensitive groups such as pregnant and lactating women and young children. Deep-rooted beliefs about food can present barriers that inhibit adoption of new, more nutritious food consumption practices. These barriers are in turn compounded by low levels of formal education in rural areas of Nepal and by strong hierarchies in families in which older, more traditionally-minded family members make decisions about food consumption in the household. This article explores the importance of engaging multiple stakeholders within the household in order to change cultural perspectives on nutrition.

One example of a common cultural practice that affects nutrition in Nepal is the categorization of foods into ‘hot’ or ‘cold’. These categorizations, unrelated to the physical temperature of food, reflect perceptions of how foods will affect the body after consumption. During critical periods such as pregnancy, lactation and illness, it is common practice to avoid eating foods classified as ‘cold’ in order to protect the body in its vulnerable state. For example, pregnant women may be warned to avoid eating certain vitamin-rich fruits and vegetables like papaya or spinach because these foods are considered cold.

Other cultural practices that affect nutrition may affect various household members differently. Baby boys are commonly exclusively breastfed until six months of age, while baby girls are generally offered their first solid food earlier, at five months of age. In some cultural groups, women family members eat meals last, after everyone else in the family has had their fill. Ultimately, these practices can contribute to poorer health status, including anemia and malnutrition for children under three and for women during pregnancy and lactation.

Lack of nutrition knowledge is the main reason for the persistence of traditions that negatively influence nutrition status in the community. In order to address this situation, the Rural Institution for Community Development (RICOD) has been disseminating appropriate nutrition knowledge and skills in rural communities of the southern Lalitpur district. In these trainings RICOD raised awareness about effective nutrition practices aimed not only at mothers of young children and pregnant women but also at those who traditionally hold decision-making power in their households, namely, the women’s in-laws and husbands. In order to ensure that such trainings, which aimed to change traditional practice, were also  culturally sensitive, RICOD’s staff focused on providing general nutritional advice, such as counseling pregnant women to consume diets rich in vitamins, rather than targeting and criticizing specific cultural practices, like avoiding green leafy vegetables (a ‘cold’ yet vitamin-rich food) during pregnancy.

Trainings generally targeted women with young children by teaching an in-depth nutrition curriculum in mothers’ groups and then reviewing and doing refresher trainings on that curriculum. Mothers-in-law were also often part of these groups, so these workshops included more powerful players in household decision-making. Additionally, RICOD organized workshops for men in the targeted households, because decisions in Nepal about buying food and about agricultural plans are traditionally made by male heads-of-household, including fathers-in-law and husbands of women with young children. Therefore, men’s understanding was crucial for households to start acting on new nutrition knowledge. RICOD also promoted learning and sharing opportunities between women and men on the importance of nutrition for women and children during vital periods. These meetings aimed to lower cultural barriers to acting on good nutrition knowledge.

More recently, RICOD organized nutrition awareness trainings for school-aged adolescents (men and women) to provide knowledge to younger generations. Not only are the nutrition facts important for these adolescents to know as future parents, these young men and women also tend to be well-placed to disseminate the information to their parents and neighbors.

In addition to teaching new information, RICOD recognized the importance of peer education in changing traditional practice. To promote learning and sharing opportunities among women, RICOD worked with existing mothers’ groups linked to local health posts to strengthen their functioning. Through these meetings, participants exchanged ideas and shared knowledge about nutrition and health. Participants then also shared the new knowledge they gained from the groups with their neighbors and relatives. RICOD also promoted kitchen gardening and empowered women by providing access to capital via revolving loans administered by these women’s groups. Kitchen gardens increased women’s access to homegrown vegetables while revolving loans stimulated small enterprises that in turn generated additional income for households to buy nutritious food.

Besides promoting peer education through women’s groups, RICOD provided in-depth training to volunteer peer educators on good nutrition practices. Peer educators are youth residing in the local community who regularly visit targeted households to encourage them to practice good eating habits. Additionally, some peer educators attend the monthly mothers’ group meetings, where they lead discussions on nutrition-related topics.

RICOD’s work has led to important learnings for future nutrition programs. In particular, understanding traditional beliefs and eating habits is essential for knowing how to promote improved nutrition practices. Broad dissemination of nutrition information should take place in order to teach many people within a community. RICOD also found that working with more than just one household member was a key to healthy changes in traditional practices. By training both men and women and both younger and older generations on the importance of nutrition and good nutrition practice, RICOD was more effective in creating change within households. Not all of this change came easily. Changing older generations’ traditional beliefs was a challenge, since it takes a long time to change traditional practice and behavior. Even now, not everyone has changed their traditional practices. RICOD’s work and encouraging results demonstrate, though, that exposure to better eating habits and continuous follow-up can lead to changed knowledge, skills and practice.

Additionally, peer education and coordination by non-governmental organizations like RICOD with other health providers, like Nepal’s Female Community Health Volunteers, are important so that people regularly hear the same message about good nutrition practice from multiple sources. Mobilization of local community members to disseminate nutrition knowledge can help lower cultural barriers through peer education and regular follow up. That regularity is key to changing long-held practices. Changing tradition is a slow process, but new knowledge and understanding can over time lead to positive changes in nutritional practice and health.

Honey Gurung is field coordinator and Ram Hari Ghimire is executive director for the Rural Institution for Community Development (RICOD).

Learn more

Adhikari, Ramesh Kant. Food Utilization Practices, Beliefs and Taboos in Nepal: An Overview. United States Agency for International Development, Global Health Technical Assistance Project (May 2010). Available at pdf.usaid.gov/pdf_docs/pnaeb772.pdf.

Alonso, Elena Briones. The Impact of Culture, Religion and Traditional Knowledge on Food and Nutrition Security in Developing Countries. FOODSECURE Working Paper No. 30 (March 2015). Available at www3.lei.wur.nl/FoodSecurePublications/30_briones.pdf.

Khatry, Subarna K., Steven C. LeClerq and Sharada Ram Shrestha. “Eating Down in Pregnancy: Exploring Food-Related Beliefs and Practices of Pregnancy in Rural Nepal.” Ecology of Food and Nutrition 45 (2006): 253-278. Available at www.k4health.org/sites/default/files/Eating%20down%20Nepal%20article_Caroline%20sent.pdf.

Nutrition: more than just food (Winter 2017)

[Individual articles from the Winter 2017 issue of Intersections will be posted on this blog each week. The full issue can be found on MCC’s website.]

Nutrition and malnutrition are often viewed as technical matters of food consumption. Are we eating the right amount of food? Are we eating the right kinds of food to get the vitamins and minerals our bodies need? This technical view of nutrition, however, misses many of the potential barriers to getting the right amounts of the right kinds of foods. In doing so, it also obscures opportunities to address the cultural and social barriers to improve nutrition. Authors in this issue of Intersections explore ways to expand our understanding of nutrition in order to broaden opportunities for improving nutrition practices and outcomes.

Although much nutrition programing still emphasizes trainings on dietary diversity or increased access to food, the idea that strong nutrition programs require a broad approach is not a new one. In the 1990s, UNICEF developed a three-layer framework of factors that affect good nutrition. At the individual level, malnutrition can be caused by immediate factors, such as lack of food or inadequate dietary diversity. At the household and community level, underlying factors like child care practices, income poverty or an unhealthy environment can also lead to malnutrition. At the societal level, social, cultural, economic and political factors contribute to individual and household willingness and ability to practice good nutrition.

This framework not only expands the picture of barriers to good nutrition beyond a technical question of calories and vitamins: it also broadens the scope of nutrition interventions. Nutrition programing can work from any of these levels, although, as we see in the articles below, work that addresses barriers to good nutrition at a variety of levels has the most potential to impact nutrition positively.

In this issue, we seek to look at how issues of culture, gender, household power dynamics and a changing environment contribute to malnutrition. Contributors from Nepal, Bangladesh, Burkina Faso and Canada outline contextually appropriate approaches for combatting malnutrition at different levels. While these authors write from diverse contexts, a commonality emerges from their articles, namely, the importance of local knowledge of the social and cultural context and strong community relationships in developing relevant nutrition interventions.

Leah Reesor-Keller and Martha Kimmel serve with MCC in Nepal as co-representative and food security advisor, respectively.

Learn more

Meeker, Jessica, Stephen Thompson, Inka Barnet. Nutrition Topic Guide. (October 2013). Available at www.heart-resources.org/wp-content/uploads/2013/10/HEART-Nutrition-Topic-Guide.pdf.

European Union and UNICEF. Multi-Sectoral Approaches to Nutrition: Nutrition-Specific and Nutrition Sensitive Interventions to Accelerate Progress. Available at www.unicef.org/eu/files/101322_000_Unicef_Brief_NutritionOverview_A4_v1r15.pdf.

Mobilizing local faith communities to improve health outcomes

[Individual articles from the Fall 2016 issue of Intersections will be posted on this blog each week. The full issue can be found on MCC’s website.]

Churches have long functioned as leading actors in healthcare provision. Today, faith-based organizations (FBOs) have a high profile within the changing healthcare landscape, both in the United States and beyond. This article assesses FBO roles in healthcare and the opportunities for FBOs to improve health outcomes for the most vulnerable. Not only do FBOs draw upon healthcare practitioners motivated by religious conviction to care for the sick, their connections with congregations and other local faith
communities provide them greater access to economically and socially marginalized communities than government or for-profit health providers often have, positioning them to positively influence healthcare outcomes in those communities.

Different factors impel individuals and groups to care for the sick and vulnerable. Historians contend that many early healthcare institutions, in contrast to profit-driven systems, were motivated by faith commitments that mandated followers to care for the poor and heal the sick (Risse, 1999). The care provided in these early hospitals prompted the Roman emperor Julian to remark: “Now we can see what it is that makes these
Christians such a powerful enemy of our gods. It is brotherly love which they manifest toward the sick and poor.”

In many countries, healthcare over the past 40 years has shifted from a social service for the most vulnerable to a trillion dollar, profit-driven industry. Amidst this shift, however, faith-based health services have continued to provide an important gateway of care for economically and socially marginalized communities around the world. In many developing countries, faith-based health services provide up to 70% of healthcare to
the most vulnerable (WHO, 2007).

Core values that drive Christian FBOs are compassion and love for one’s fellow human beings created in God’s image, human beings in whom Christ is encountered (Matthew 25). These values shape an understanding of discipleship as including “consciousness of others’ distress together with a desire to alleviate it” (Neufeldt, 2011). These motivations for Christian health services have not necessarily changed over the years. However, the complexities for FBOs in providing access to care have increased dramatically as they not only navigate relationships with the public healthcare sector (government-run hospitals, clinics and more), but also face the rapid growth of the for-profit healthcare industry.

One response of healthcare FBOs has been to undertake more collaborations with the public healthcare sector, collaborations that build on the distinctive strengths of both partners. The public healthcare sector has financial, material and political resources that are critical to the development and implementation of health services, especially to marginalized communities. Likewise, the faith-based sector has a reputation for successfully mobilizing communities to action by leveraging their engagement and trust. As churches and FBOs collaborate with the public sector, there is an increased possibility for success. In the Democratic Republic of Congo, for example, the Congolese government
partners with faith-based hospitals (many of them initially founded by foreign mission agencies and then later turned over to the control of Congolese churches) to implement national health priorities and extend the state’s ability to provide healthcare to isolated communities: Congolese Mennonite hospitals, with support from MCC, have been part of such efforts. Public healthcare institutions and the faith-based healthcare sector need one other and increasingly recognize the wisdom in collaboration. Ray Chambers, a United Nations Special Envoy, has acknowledged that ambitious global health targets such as the Sustainable Development Goals “would simply be unachievable without the engagement of the faith community” (quoted in Duff and Buckingham, 2015).

One method of improving health outcomes at the community level is through the implementation of care groups. The care group approach is a community-based strategy for promoting behavior change by engaging local health educators. Groups are made up of ten to 15 volunteers who regularly meet together with FBO staff for training and supervision. Care groups create a multiplying effect to equitably reach targeted households with activities aimed at promoting specific health behaviors (such as getting one’s children vaccinated and adoption of breastfeeding). The community-based volunteers who are central to the care group model are enmeshed in the lives of target communities and are thus well positioned to catalyze and reinforce the creation of new community health norms.

Churches and other local faith communities are typically key sources of volunteers for the care group model. Relationships fostered among care group volunteers and their neighbors in targeted communities are activated through the care group model to create more durable change in health behaviors. A review assessing the effectiveness of community-based interventions using care groups to promote maternal and child health
and nutrition has shown the benefits of such approaches when it comes to reducing maternal illness, stillbirths and newborn deaths (Lassi, 2010). These positive impacts can be traced to changes in household behaviors and practices, such as improved tetanus immunization rates, use of clean birth kits, facility births, early initiation of breastfeeding and seeking care for newborn illnesses.

Through the new Luann Martin Legacy Fund initiative in eastern Africa, MCC is partnering with local Anabaptist groups and other faith-based organizations who are adopting the care group model to promote maternal and child health and nutrition. Projects in this initiative will mobilize volunteers in local faith communities to participate in care groups
resourced by FBOs that promote new health behaviors among pregnant women and mothers of newborns and young children. FBOs participating in this initiative will give particular attention to how the volunteer-based care group health promotion activities intersect and collaborate with governmental health departments so that care group efforts help meet national maternal and child health and nutrition goals.

The effort to build healthy communities around the world, especially for vulnerable groups and those in crisis, will require the collaborative efforts of the faith-based and public healthcare sectors. Leveraging the trust and reach of churches and faith communities is an essential element in the ongoing efforts to increase positive health outcomes for economically and socially marginalized communities.

Beth Good is MCC health coordinator and lives in eastern Congo.

Learn more:

Duff, Jean F. and Warren W. Buckingham. “Strengthening of Partnerships between the
Public Sector and Faith-Based Groups.” The Lancet 386/10005 (2015): 1786-1794.

Lassi, Zohra S., Batool A. Haider and Zulfiqar A. Bhutta. “Community-Based Intervention
Packages for Reducing Maternal and Neonatal Morbidity and Mortality and Improving
Neonatal Outcomes.” Journal of Development Effectiveness 4/1 (2012): 151-187.

Neufeldt, Aldred H. “An Ethos of Faith and Mennonite Mental Health Services.” Journal of Mennonite Studies 29 (2011): 187-202.

Olivier, Jill, et al. “Understanding the Roles of Faith-Based Health-Care Providers in Africa: Review of the Evidence with a Focus on Magnitude, Reach, Cost, and Satisfaction.” The Lancet 386/10005 (2015): 1765-1775.

Risse, Guenter B. Mending Bodies, Saving Souls: A History of Hospitals. New York: Oxford
University Press, 1999.

World Health Organization (WHO). “Faith-Based Organizations Play a Major Role in HIV/AIDS Care and Treatment in Sub-Saharan Africa.” February 8, 2007. Available at
http://www.who.int/mediacentre/news/notes/2007/np05/en/.

Luann Martin Legacy Fund announcement: https://mcc.org/stories/mcc-receive-1-million-legacy-gift