Into Africa: A Transnational History of Catholic Medical Missions and Social Change 9780813566238

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Into Africa

Into Africa A Transnational History of Catholic Medical Missions and Social Change

BARBRA MANN WALL

RUTGERS UNIVERSITY PRESS NEW BRUNSWICK, NEW JERSEY, AND LONDON

LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA

Wall, Barbra Mann, author. Into Africa : a transnational history of Catholic medical missions and social change / Barbra Mann Wall. pages cm Includes bibliographical references and index. ISBN 978–0–8135–6622–1 (hardcover : alk. paper) — ISBN 978–0–8135–6623–8 (e-book (web pdf)) — ISBN 978–0–8135–7288–8 (e-book (epub)) 1. Catholic Church—Missions—Africa, Sub-Saharan. 2. Missions, Medical—Africa, Sub-Saharan. 3. Medical personnel—Africa, Sub-Saharan. 4. Women missionaries—Africa, Sub-Saharan. 5. Medical care—Africa, Sub-Saharan.

I. Title.

RA390.A357W35 2015 610.690967—dc23 2015002727 A British Cataloging-in-Publication record for this book is available from the British Library. Copyright © 2015 by Barbra Mann Wall All rights reserved No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, or by any information storage and retrieval system, without written permission from the publisher. Please contact Rutgers University Press, 106 Somerset Street, New Brunswick, NJ 08901. The only exception to this prohibition is “fair use” as defined by U.S. copyright law. Visit our website: http://rutgerspress.rutgers.edu Manufactured in the United States of America

For Deb

CONTENTS

List of Figures

ix

List of Tables

xi

Acknowledgments

xiii

Abbreviations

xvii

1

Medical Missions in Context

2

Nursing, Medicine, and Mission in Ghana

32

3

Shifting Mission in Rural Tanzania

64

4

Catholic Medical Missions and Transnational

1

Engagement in Nigeria 5

92

Transnational Collaboration in Primary Health Care

6

120

Appraising Women Religious and Their Mission Work

152

Note on Sources

171

Notes

175

Index

219

vii

FIGURES

2.1 Mother and baby with Sister Paula D’Errico, Berekum, Ghana, sometime in late 1950s or early 1960s

40

2.2 Anatomy class with Sister Alice Hanks, tutor, Berekum, Ghana, 1963

42

2.3 Hanging an IV drip in room with crucifix, Uganda, 1968

43

2.4 Holy Family Hospital, Berekum, Ghana, taken approximately 1959

44

2.5 Sister Maria Hornung with pharmacy assistants in Uganda hospital, 1966

54

3.1 Sister Joan Michel Kirsch with young boy, c. 1950s

67

4.1 Sister Joseph Therese Agbasiere, a Holy Rosary Sister, comforting a mother who had dusted her baby with chalk in an attempt to heal it. Taken during the Nigerian Civil War

108

5.1 Nutrition class, Berekum, Ghana, 1972

127

5.2 Sister Mary Ann Tregoning, Ghana, c. 1980

129

5.3 Sister Maria Hornung, phramacist, on medical safari in a Ugandan village, 1964

139

6.1 Medical Mission Sisters in front of the White House, Washington, DC, participating in a justice march, October 1998

164

6.2 A Catholic nun runs a stall advertising the use of condoms to prevent HIV/AIDS spreading in Pietermaritzburg, KwaZulu Natal, 2001

166 ix

TABLES

2.1 Statistics of Holy Family Hospital, Berekum, 1953–1985

36

2.2 Personnel and Procedures at Holy Family Hospital, Berekum, 1958–1966

55

2.3 Sample of Patients Treated at Holy Family Hospital, Berekum, January 1961

60

3.1 Monthly Statistics, Kowak Dispensary, 1951–1956

70

4.1 Income and Expenditures, St. Mary’s Hospital, Urua Akpan, 1953–1966

114

5.1 Topics in PRHETIH Program, 1979

xi

132

ACKNOWLEDGMENTS

I am indebted to the staffs and archivists of many repositories for their assistance in this project: Sister Jane Gates, MMS, Archives of the Medical Mission Sisters in Fox Chase, Pennsylvania; Annaig Boyer, Archives of the Medical Mission Sisters in Acton, United Kingdom; Sister Catherine Dwyer, MMM, and Sister Isabelle Smyth, MMM, from the archives of the Medical Missionaries of Mary in Drogheda, Ireland; Ellen D. Pierce, Archives of the Maryknoll Sisters, Ossining, New York; Lucy McCann, Archivist, Bodleian Library of Commonwealth & African Studies at Rhodes House, Oxford University, Oxford, United Kingdom; Ralph Bates, Oxford Center for Mission Studies Library, Oxford University, Oxford, United Kingdom; Belinda Michaelides, Secretary of the Wellcome Unit for the History of Medicine, Oxford, United Kingdom; Sister Mary Nesta, IHM, my contact for the Sisters of the Immaculate Heart of Mary, Mother of Christ, in Minneapolis, Minnesota; Sister Ursula Preusser, MMS, Archives of the Medical Mission Sisters in Berekum, Ghana; the Holy Rosary Sisters in Killeshandra, Ireland; and Susan Eason at the Catholic Archives of Texas in Austin, Texas. In all my work, I have valued the intellectual community of the University of Pennsylvania. Along with Joan Lynaugh, Julie Fairman, Patricia D’Antonio, and Cynthia Connolly, colleagues at the Barbara Bates Center for the Study of the History of Nursing were most generous with their expertise and encouragement. They read my work with sharp minds, always providing nuanced comments while providing a unique friendship. My thanks to Dean Afaf Meleis and other administrators at Penn who granted me a sabbatical to write the book. I also am grateful for the friendship and support of historians of nursing Arlene Keeling, Sandra Lewenson, and Barbara Brodie. And I acknowledge friends and colleagues xiii

ACKNOWLEDGMENTS

xiv

who also study women religious and with whom I have traveled and presented papers: Susanne Malchau Dietz, Carmen Mangion, Carolyn Bowden, Sonya Grypma, and Helen Sweet. To all of these friends, I am grateful for their support. I have benefited by attendance at several international conferences on colonial and African health and medicine where I learned from international and Africa-based scholars. These include: the International Conference on Nursing History in Berlin, Germany, May 12–14, 2011; History of Health Care in Africa Conference, Basel, Switzerland, September 14–15, 2011; Conference on Humanitarianism, Nursing and Missions: How to Study Knowledge Exchanges in a Historical, Transnational Perspective, Bergen, Norway, Sept. 22–23, 2011; the History of Women Religious in Britain and Ireland Conference, Dublin, Ireland, June 2012; Nursing History in a Global Perspective, International Nursing History Conference, Kolding, Denmark, August 9–11, 2012; New Directions in the Histories of Health, Healing, and Medicine in African Contexts Workshop, August 19–21, 2012, KwaZulu-Natal, South Africa; and the UK Association for the History of Nursing Colloquium, History of Colonial and Post-Colonial Nursing, July 4, 2013, Oxford, UK. I also have used a number of oral histories for the book. I offer a special acknowledgment to my students, Madeline Reckart and Hillman Scholar Lauren Johnson at the University of Pennsylvania School of Nursing who interviewed the sisters with me. Thanks to the Sisters of the Immaculate Heart of Mary, Mother of Christ: Sisters Mary Nesta, Maria Chinweze Enujiofor; Maureen Bernardine Onovo; Nkiruka Okafor; Immaculata Uwanuakwa; and Maria Nkiru. I am grateful to the Medical Mission Sisters: Sisters Jane Gates, Joan Marie Doud, Margaret Moran, Mary Ann Tregoning, Catherine Shean, Alice Hanks, and Rose Kerschbaumer. And thanks to the many Medical Missionaries of Mary who asked that I not use their names. I also want to express my thanks to the University of Pennsylvania for its generous support in funding this project through a University Research Foundation Grant; the Provost Undergraduate Research Mentorship (PURM) Award with my student Madeline Reckart; and the School of Nursing’s F(our)ULD Undergraduate Research Award that I received with my Hillman Scholar Lauren Johnson. Both Madeline and Lauren presented

ACKNOWLEDGMENTS

xv

papers based on this research at the Southern Association for the History of Medicine and Science Conference, Charleston, South Carolina, February 21, 2013; and the Second Agnes Dillon Randolph International Nursing History Conference, University of Virginia, Charlottesville, Virginia, March 15–16, 2013. Portions of the following have been used with permission of the publisher: “Beyond the Imperial Narrative: Catholic Missionary Nursing, Medicine and Knowledge Translation in Sub-Saharan Africa, 1945–1980,” in Transnational and Historical Perspectives on Global Health, Welfare, and Humanitarianism, edited by E. Fleischmann, S. Grypma, M. Marten, and I. M. Okkenhaug, 90–109 (Kristiansand, Norway: Portal Forlag, 2013). At Rutgers University Press, Peter Mickulas, Rima Apple, Janet Golden, Carrie Hudak, Joy Stoffers, Allyson Fields, Marilyn Campbell, Margaret Case, and others have been dependable editors and have always been enthusiastic about the manuscript. They have encouraged me all along the way, and I thank them for their continued support. Finally, I acknowledge the love and support from my husband of thirty-four years, Robyn Wall, who, as always, is my best editor and friend; my son Austin, who never ceases to delight me; my long-time friend Cynthia Cantwell whose support and love for fifty years has never ceased; and to my sister, Debra Mann, to whom I dedicate the book. Through my many years of research and writing, she has never lost faith in me. Her love and support has sustained me far beyond the life of this book.

ABBREVIATIONS

CMC

Christian Medical Commission

CMSW

Conference of Major Superiors of Women

CRS

Catholic Relief Service

HFH

Holy Family Hospital

IHM

Sisters of the Immaculate Heart of Mary Mother of Christ, Nigeria

MMM

Medical Missionaries of Mary

MMMA

Medical Missionaries of Mary Archives

MMS

Medical Mission Sisters

MMS-B

Medical Mission Sisters Archives, Berekum, Ghana

MMS-F

Medical Mission Sisters Archives, Fox Chase, Pennsylvania

MMS-UK

Medical Mission Sisters Archives, Acton, UK

MSA

Maryknoll Sisters Archives, Ossining, NY

NAI

National Archives of Ireland, Dublin

OCMS

Oxford Center for Mission Studies, Oxford, UK

PRHETIH

Primary Health Training for Indigenous Healers

RH

Bodleian Library of Commonwealth & African Studies at Rhodes House, Oxford University, Oxford, UK

TBA

Traditional Birth Attendant

WCC

World Council of Churches

WHO

World Health Organization

xvii

Into Africa

1 Medical Missions in Context

Following World War II, national identities and international alliances shifted rapidly, and many colonized nations found courage and opportunity to move toward independence. In sub-Saharan Africa, as the voices of independence grew louder, British and other colonizers came under international criticism and increasingly were unable to sustain their colonies. Within a decade, they began moving out in droves. Consequently, indigenous populations struggled to realign their countries and begin the arduous process of self-rule. Catholic women’s religious congregations, whose work in Africa had been hampered by the war, now saw themselves playing a supportive role in this transition process by expanding their medical missions. They did so in the context of an accelerating Catholic missionary movement; in the 1950s there were more foreign missionaries in Africa than ever before.1 This book addresses an important but largely neglected aspect of medical mission work: its transnational character involving the mobilization of religious women, their ideas, and their institutions across national borders and continents; the groups with whom they aligned; the outcomes of their work; and how their organization and mission changed during the decolonization and independence periods.2 The most dramatic growth of Christianity in the late twentieth century has occurred in Africa, and Catholic missions have played major roles. According to the 2010 Symposium of Episcopal Conferences of Africa and Madagascar, “in 1900, there were two million Catholics in Africa; today, there are over 165 million. . . . 14 percent of Catholics worldwide now live 1

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there, nearly half of the children in Catholic elementary schools study there, and 43 percent of the world’s adult baptisms—over a million a year—take place there.” More Catholic hospitals are in Africa than in North and Central America collectively. In 1951, there were 4,437 African sisters working continent-wide, while currently the African continent is second only to Asia in religious vocations. “Between 1998 and 2007 . . . the number of women religious grew by over 10,000, from 51,304 to 61,886.”3 This current demographic shift can be viewed as a woman’s movement: even though men typically are the theologians, women are the most numerous practitioners.4 Indeed, women have been key players in the transformation of mission from one that expanded the Catholic Church and biomedical care to that of helping the poor to claim their rights and dignity within their own social systems. In the process, encounters between Africans and women from various religious congregations involved multiple negotiations that challenged a one-dimensional notion of a compliant indigenous population subjected to an overbearing Western presence. As Catholic sisters developed networks among those they served, they participated in various intercultural exchanges, and multidirectional movements of influence and ideas occurred.5 American, European, and indigenous healers eventually borrowed from each other as they fused different medical systems into their own. In addition, biomedically trained African nurses and auxiliaries played important roles in negotiations between Western-educated health care practitioners and local patients.6 By examining the lived reality of mission work on the ground where health care actually took place, one sees how American and European women’s encounters with people from different African countries intertwined with political movements, theological changes, and beliefs about medicine and nursing. In her 1945 publication, Mission for Samaritans, Anna Dengel, founder of the Society of Catholic Medical Missionaries, or the Medical Mission Sisters (MMS), invited her readers to contemplate a particular framework for mission work that combined religious commitment and medical science. She saw it as a “branch of missionary work through which skilled medical care is given to the sick and poor of mission countries, as a means of relieving their physical suffering and bringing to them a knowledge and appreciation of our Faith.” Yet the sisters would care for “all whom we see

MEDICAL MISSIONS IN CONTEXT

3

sick and suffering, even if we know that they will not therefore accept our Faith.”7 Although Mother Anna recognized that missionary priests and sisters had worked for centuries in relieving the sick, what was new for her religious community was “organized, systematic medical care by people . . . who have been trained in the medical field as doctors, nurses, or technicians.”8 She was convinced of the superiority of scientific knowledge, and she wanted to make it available to others. Founded in 1925, the MMS were the first group of its kind in the medical field in being both professional and religious, and the first Catholic congregation of women to work as physicians, surgeons, and obstetricians.9 To Mother Anna, the MMS would be “good Samaritans” who would minister to the ill and to those who fell victim to superstition; most important, science and expert knowledge were essential. She also laid the groundwork for social justice when she wrote, “It is the tremendous debt which we, the white race, owe to the peoples subjected and exploited by our forefathers.”10 Even if a “utopia of medical care were established, the problems would not be solved. For the roots of the conditions we have just examined lie far deeper than in a mere lack of medical care.”11 Although she did not question the expansion of missionary authority outside Europe and the United States, she framed her medical mission in direct opposition to imperialism driven by selfish greed by calling for a revision of social and economic conditions. Even though the term “social justice” was not in common usage at the time, and it would not enter sisters’ regular vernacular until the 1960s, her emphasis was still very much in that mold.

Transnational Processes In this book, I explore transformations in the Catholic medical mission movement in sub-Saharan Africa from 1945 to 1985 by situating the study of Catholic sisters in a transnational framework. I recognize that global, world, transnational, and international histories are contested terms.12 This book is framed within what Lynn Hunt describes as “micro-historical” transnational processes at work when “histories of diverse places become connected and interdependent.”13 It follows guidelines set by C. A. Bayly, who sees transnational history as a “range of connections that transcend politically bounded territories and connect various parts of the world to

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one another. Networks, institutions, ideas, and processes constitute these connections.”14 In this respect, Catholic medical and nursing mission history is one that witnessed sisters’ practices continually shaped and reshaped by their interactions with indigenous people, government agencies, global networks, wars, famines, and the structures and demands of the Catholic Church. As a transnational organization, the Roman Catholic Church’s influence emanates from the Vatican in Rome to national churches in countries all over the world to dioceses at the local level. Despite the Church’s classic patriarchy, women have had access to resources and status through entrance into religious orders to become sisters, or nuns.15 The Catholic sisters represented in this book are part of multinational religious congregations and orders with members from Europe, Asia, Africa, South America, and North America. Case studies of their work are used to examine how women in a transnational church became potent actors in health care both at the local and global levels. Catholic women’s religious organizations involved practices with many groups of women and men as they built acute and primary health care delivery systems in sub-Saharan Africa. While this can be seen as an aspect of nation building, nuns’ work transcended traditional nation/state boundaries: they were bound by stronger ties of gender and religion even as they challenged gendered conventions. At the same time, they worked in different kinds of relationships with transnational actors: sometimes they competed, sometimes they collaborated, and other times they integrated their resources.16

Colonial and Mission Medical Services Colonial medical services in sub-Saharan Africa began as a means to care for the health of whites who lived in large cities. In contrast, it was Christian missions that provided the majority of medical and nursing care to rural Africans.17 Missionaries also provided most of the care to persons with leprosy. In Catholic hospitals and clinics today, indigenous workers constitute the majority of personnel. Yet expatriate sisters were the ones who opened, managed, financed, and taught in hospitals, rural clinics,

MEDICAL MISSIONS IN CONTEXT

5

schools of nursing and midwifery, and programs for auxiliary workers. They either established Catholic hospitals themselves or administered them for the local diocese. One way to secure acceptance of their religious and medical ideas was to train African nurses and midwives to replace the European and American sisters. As they carried out their health care missions, nuns were critical vehicles for knowledge construction and translation not only of Christianity but also of biomedical knowledge to African populations. They also produced knowledge about Africans that they shared with their home societies. This enterprise involved communication through books, pamphlets, and teaching materials sisters wrote for African students; magazines written for their religious orders and Catholic mission boards and donors in their home societies; and correspondence to sisters across the world. In doing so, missionaries initially used their own Western understandings to create an image of the “Other,” or “foreigner.” Over time, however, this changed as nuns identified more with the people with whom they lived and worked, which affected their policy advocacy.18 This happened in the twentieth century, when much of the mission movement peaked as secularization increased in the missionaries’ home societies.19 Secularization theory asserts that religion and religious ideals lose their influence with the modernization of society. Thus, many scholars have disregarded the significance of religion as an explanatory factor in twentieth-century history.20 Others, however, have noted that there has been little decline in individual religiosity; and at the societal level, many religions are seeking to reclaim authority in the public arena.21 Furthermore, when studying women in the twentieth century, the secularization thesis is even more problematic. As Mary Jo Neitz asserts, “women in many places fought for access to the very religious roles that men supposedly were leaving.” Indeed, “women use religion as a resource for acting in their own behalf.”22 This certainly occurred in sub-Saharan Africa over the last half of the twentieth century. As the Catholic Church faced increasingly secularizing societies at the local and national levels during decolonization and independence, Church leaders were deeply concerned about how to continue their influence. For the women in this study, “mission” meant conversion and the establishment of churches in territories where Catholicism had not yet developed. Beneath the surface, however, mission goals were being transformed.23

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Transnational cooperation was evident from the start of Catholic missions in sub-Saharan Africa. Although sisters worked in both Francophone and Anglophone Africa, this book centers on those who went to British colonies whose colonial leaders wanted English speakers. The British had established a policy of “indirect rule,” whereby they governed through traditional chiefs, and this gave African communities some say in the management of their affairs. Colonial policy was particularly advantageous for missionaries because Christianity was the religion of the colonial powers, and the missionaries had a privileged position.24 The main focus of the book is from 1945 through the decolonization and independence periods to 1985, when another key transformation in health care occurred, one resulting from the HIV/AIDS epidemic (a book in itself). It should be particularly noted that the sisters in this study did not focus on caring for white settlers or families of white missionaries. With the end of colonization, a fuller account of the encounters among religious sisters, volunteer and trained community health workers, indigenous healers, international agencies, and biomedicine becomes possible. Among the women’s religious congregations that sent the largest number of sisters overseas are the MMS from Fox Chase, Pennsylvania; the Medical Missionaries of Mary (MMM) from Drogheda, Ireland; and the Maryknoll Sisters from Ossining, New York.25 This book concentrates largely on the MMS in Ghana and Uganda; the MMM in Nigeria and Uganda; and the Maryknolls in Tanzania. It also examines the Missionary Sisters of the Holy Rosary from Ireland in Nigeria; and the Sisters of the Immaculate Heart of Mary, Mother of Christ (IHM), in Nigeria. This latter group is a congregation from eastern Nigeria where there is a strong Catholic enclave.26 By including them in the analysis, I begin to address the problem of the scarcity of African sisters’ voices. Today the IHMs have an international presence in, among other countries, the United States. The MMS and the MMM were established as multinational congregations from the beginning. The Maryknoll Sisters began with a distinctly American identity, although their membership soon internationalized. All the orders are similar in that their mission activities carried the women to many parts of the world. To differentiate their work from that of

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7

non-Catholic missionaries, the Maryknolls referred to themselves as “missioners,” and, with their permission, this term will be used for all the sisters represented in this book. Ghana, Tanzania, Nigeria, and Uganda obviously do not represent the whole continent of Africa. My focus on these areas reflects my concern with religious and medical change rather than different colonizing projects. Thus, although broad patterns emerge among the women’s religious congregations, the contexts of their work are different; and their influences on health care reveal diverse missionary experiences. Because North Africa represents quite different patterns from sub-Saharan Africa in terms of religion and development, it is not discussed here. Catholic sisters take vows of poverty, chastity, and obedience, and Catholic tradition views them as ideal missionaries, although a lay mission movement also occurred. For the Catholic Church, marriage is acceptable but celibacy is considered a higher quality. Whereas Protestants were initially reluctant to hire women for missions, eventually Protestant women joined the mission field in great numbers as wives or as single women with professional skills such as teaching, nursing, or evangelism.27 They especially worked for women and children, which allowed them to carve out a niche and power base to participate in ministry. Catholic missioners worked with women and children as well. Influenced by the Church’s emphasis on home and family, women religious ran hospitals and clinics, operated maternal and child care clinics, recruited women for religious congregations, and educated women in schools of nursing.28 A distinction from Protestant women, however, was that, as vowed, unmarried women, nuns had flexibility to be assigned anyplace in the world, and their vow of obedience assured their service wherever their superiors deemed necessary. Missions provided opportunities for leadership and adventure. In both Europe and the United States, a large number of women joined religious congregations, so that by 1920, 90,000 women, many of them from Ireland and Germany, had joined American orders. These groups peaked in the United States in 1965 with 179,954 sisters.29 At the same time, missionary life was risky, and it could serve as a means of redemption.30 In Africa, known as the “white man’s grave,” sisters’ work in health care could be a sacrificial act in which nuns prepared to die to further their Christian message.31

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Competing Interpretations The struggle to reconcile mission work and colonialism has become a key focus of academic study. Distinct shifts in historiography of missionaries have moved from celebratory encomiums to imperialistic interpretations to more nuanced analyses. To be sure, much scholarship has denounced missions for being connected to imperialism and for trying to change cultures. Academic historians of the 1960s and early 1970s were especially critical in linking missionaries with paternalism rather than any humanitarian motives. Postcolonial discourse in the 1970s created yet a different analysis: missions played a central role in creating the stereotype of the non-Westerner as uncivilized and in need of control.32 Appraisals extending into the 1990s, such as the highly influential work by Jean and John Comaroff, provided powerful critiques of missions as cultural imperialists.33 The title of William R. Hutchison and Torbin Christensen’s book, Missionary Ideologies in the Imperialist Era: 1880–1920, demonstrates this assertion that missionaries used Christianity as a tool of European colonial empires.34 In 2002, Andrew Orta analytically positioned missionaries as “oppositions between local and global, indigenous and foreign.”35 Many of these scholars were reacting to hagiographic mission historiography that represented missionaries in heroic terms.36 Megan Vaughan’s Curing Their Ills, for example, analyzes British Protestant medical missionary discourse during the colonial era and its representations of Africans. Rhetoric revealed that missions used their medical work as “part of a program of social and moral engineering through which ‘Africa’ would be saved.” Vaughan is sensitive to the limitations of using missionary language as evidence for actual encounters on the ground, yet her work has held command over academic audiences for years.37 When they first went to sub-Saharan Africa, Catholic missioners participated in both evangelistic and civilizing discourse, with their hospitals serving as important places for conversion. This book argues that the 1960s and 1970s were watershed years for change for Catholics, yet mission historiography on Protestants shows an earlier trajectory of change. Markuu Hokkanen’s analysis of Scottish missionaries in northern Malawi during colonization is especially significant for its consideration of the key roles of nurses in knowledge transfer and education of the Western

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medical message. While he points out explicit links between conversion and medicine in published missionary accounts, he notes a lack of conversion rhetoric in unpublished primary sources.38 Studies of Scandinavian Protestant missionaries show a similar pattern, with post–World War I being a significant time. Inger Marie Okkenhaug, for example, situates women missionaries’ work with survivors of the Armenian massacre within a changed environment as missionaries became relief workers. Others note a change in the interwar years as mission goals became more secular and less focused on conversion.39 Medical histories of the African continent have grown over the past several decades. These include studies on medical pluralism in Africa as well as mission hospital histories.40 Scholars such as J.D.Y. Peel focus on inconsistencies of the colonial project, showing how some missionaries opposed colonial powers. He notes the importance of religious change and critiques studies that “overplay the ties between conversion and conquest, between Christianity and colonialism.”41 Adrian Hastings finds variations in mission and colonial leaders’ relationships in the early colonial period depending on when the missions began. Missionaries who arrived before colonialism often developed good relationships with local Africans and were more likely to criticize the colonial project.42 Terence Ranger and others note that missionary practices are themselves nuanced and localized according to specific contexts. These insights are supported by studies on French missionaries that show how they worked both with and against European colonial powers, Rome’s authorities, and local populations.43 Scholars of Africa such as E.A. Ayandele, Elizabeth Isichei, and Augustine S. O. Okwu have particularly criticized the Christian missionary movement in independent Africa, arguing that white missionaries acted in their own interests rather than those of blacks. John Manton has analyzed the interactions between the MMM and colonial and international groups in leprosy work, and he demonstrates how the Catholic Church maintained its control over its institutions during the decolonization period.44 By contast, Lamin Sanneh has shown how a new generation of Africans became more vocal about religion over the nineteenth and twentieth centuries. A “new and educated class of African leaders” took responsibility for modernizing Africa “as a postslavery society that is as committed to reform as it is to renewal of custom and tradition. The

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instrument for this double task belonged with the idea of mission as an intercultural process.”45 This book builds on other scholarship on medical missions. Angelyn Dries has analyzed Catholic missions in the American context, but she has not placed mission work in a transnational frame. Dana L. Robert has written extensively about Christianity as a world religion and women’s place in global missions, but much of her work has centered on Protestant women. At the local level, Charles M. Good has examined London’s Universities’ Mission to Central Africa from precolonial times to independence. He argues that technological advances in medicine and steam (locomotives and steamships) along with theology allowed missionaries to have marked influence over local populations. Other scholarship has focused on the ways in which hospitals were sites of negotiation between Africans and practitioners of biomedicine. For example, John Illiffe discusses the important role of tribal dressers in Uganda, Kenya, and Tanzania as intermediaries between Europeans and Africans. Nancy Rose Hunt’s influential work on missions in the Congo analyzes the complexities between missionaries’ biomedical practices and local childbirth practices, viewing them as entanglements whereby some African women took advantage of medicalized childbirth. She shows that many local Africans chose sisters’ hospitals in great numbers even if they had to pay fees. Others have examined colonial-era missions in Zambia and Uganda. I am particularly influenced by Helen Sweet and Anne Digby, whose scholarship on South Africa reveals knowledge exchange in both ways between nurses from that country and those from abroad. I also acknowledge Warwick Anderson’s call to “listen for the global circulation— not merely the transmission from Europe—of metaphor, assumption, and practice,” by including a variety of people and organizations that collaborated in health care across continents.46

Background of Catholic Medical Missions Most of the aforementioned studies have relevance to missionary ventures in the nineteenth and early twentieth centuries, and they rarely focus on Catholic care givers. Yet Catholics have a distinct trajectory. The Catholic Church centrally controls its missions in ways individual Protestant churches do not. In 1622, Pope Gregory XV established Propaganda Fide,

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also known as the Congregation for the Evangelization of Peoples, which to this day directs Catholic missionary work all over the world.47 Catholic sisters and priests had gone to Angola and the Congo as early as the 1500s, and Propaganda Fide’s establishment in the 1600s was crucial to countering Dutch and English explorations to new colonies in Africa, Asia, and the Americas. Rome perceived the very real threat of the spread of Protestantism, and the Church sent missionaries from established religious orders such as the Jesuits, Franciscans, and Dominicans.48 Protestants undertook mission activity in Africa in association with the abolitionist movement in the last half of the eighteenth century, especially in West Africa.49 Yet missions did not come about only from European interests. In the nineteenth century, for example, small settlements of African Christians developed in Sierra Leone and Liberia, each with their own indigenous leaders. With colonial conquest in the late nineteenth century, medical mission activities accelerated. This coincided with medical science research that was intensifying in Europe and America.50 Protestant missions also expanded with the student mission movement that began in the late 1800s after the Spanish-American War, when the United States began its own colonial experiment in the Philippines. These students went to India, China, Africa, and Latin America. As Robert asserts, they viewed missions “as part of a progressive social movement to spread the gospel—and the best ideals of democracy— around the world.” By 1900, more than half of the 6,000 American Protestant missionaries to foreign countries were women.51 In the late nineteenth century, new Catholic mission congregations were founded for overseas missions. Instead of traditional mission orders such as the Jesuits, societies that had formed in post-revolutionary France such as the Holy Ghost Fathers (also known as the Spiritans) and the White Fathers became more numerous. The number of sisters also grew, with some orders established to work with priests and brothers. For example, in 1869, the Missionary Sisters of Our Lady of Africa, or the White Sisters, were founded in Algeria to supplement the work of the White Fathers.52 As well, much of Catholic mission work in the nineteenth century was in North America, where European and American religious orders of women and men ministered to many immigrants. This situation did not change until 1908, when Propaganda Fide declared that the United States

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was no longer mission territory. At that time, the American Catholic Church began assuming greater responsibility for world missions.53 Catholics did not attend the 1910 Edinburgh World Mission Conference held by Protestant and Anglican communities, which is seen by many as the beginning of ecumenism, because Catholics were following their own path. In 1911, for example, the Catholic Foreign Mission Society of America formed and was composed of Maryknoll priests and, in 1912, sisters. When World War I disrupted European-sponsored missions, North American Catholics along with the Irish and Swiss began replacing French, Belgian, German, and Italian Catholic missionaries in worldwide missions.54 Inspired by the Protestant student movement, in 1918 the Catholic Student Mission Crusade was founded in the United States for the purpose of education about missions. It grew to more than one million young people who supported missionaries in the field.55 With the encouragement of Pope Pius XI, who advocated for expanded foreign missionary endeavors in Rerum Ecclesiae (On Catholic Missions, 1926), the number of Catholic missionaries doubled as they followed the pope’s call to plant the Church in foreign lands.56 During all of these ventures, both Catholic and Protestant missionaries uncritically believed in the superiority of Christianity and Western education and health care.57 It was also at this time that indigenous women’s congregations grew. As African women increasingly joined religious congregations, they had a variety of options. Some European bishops and sisters established African communities that could develop separately. For example, the Sisters of Our Lady Queen of Africa congregation was established in Tanganyika in 1907, and the Bannabikira Sisters became the first indigenous congregation of women in Uganda in 1910. Trained by the White Sisters, the Bannabikira Sisters numbered 152 by 1924. Also in Uganda, the Sisters of Mary Reparatrix formed in 1913, and they eventually became the Sisters of the Immaculate Heart of Mary Reparatrix.58 Mother Mary Kevin Kearney, an Irish Franciscan missionary, established the Little Sisters of St. Francis congregation in 1923 in Uganda.59 Sister Mary Charles Walker and other sisters from the Society of the Holy Child Jesus came to Nigeria in the 1920s, and they established the Congregation of the Handmaids of the Holy Child Jesus in 1931. That same year in Tanganyika, a Holy Ghost priest established the Sisters of Our Lady of Kilimanjaro.60 The Banyatereza

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Sisters were founded in 1937 in Fort Portal, Uganda, under the guidance of the Reverend Vincent McCauley. These sisters worked with the MMS in Uganda and eventually took over the administration of hospitals.61 In 1937, Bishop Charles Heerey, Vicar Apostolate in Onitsha and Owerri, Nigeria, established the Sisters of the Most Pure Heart of Mary, a congregation that eventually became the IHMs.62 In an interesting diaspora, albeit small, many of the Nigerian women trained in Ireland under the direction of the Holy Rosary Sisters and the MMM. Afterward, they returned to Nigeria where they became teachers, catechists, nurses, social workers, and medical doctors. In Ghana, the White Sisters trained the Sisters of Mary Immaculate. Although the White Sisters did not encourage indigenous vocations into their congregation, they were eventually responsible for training seventeen different African diocesan congregations all over the continent. The Franciscan Missionaries of Mary accepted Ghanaian women into their congregation, as did the Sisters of Our Lady of the Apostles. The Sister Servants of the Holy Spirit, established in Holland in 1889, trained the Handmaids of the Divine Redeemer in Ghana.63 These congregations were based on hierarchies of race and class, since white women and men from other countries initially established and administered them. Yet white sisters also faced restrictions that created difficulties as they expanded their missionary work in the twentieth century. Although they worked locally, Catholic sisters had to answer to a global Church with its male hierarchy. Before 1936, although there was no prohibition on the practice of nursing, Catholic Canon Law prohibited sisters from performing surgery or delivering babies. Scholars have attributed this ban to fears that the practice of certain skills would threaten nuns’ vow of chastity and, consequently, their vocation. Yet because many of the problems that society faced affected women, Mother Anna, Dr. Agnes McLaren, and key American, Irish, and Australian bishops lobbied the Vatican to obtain permission for nuns to become surgeons, midwives, and obstetricians in their mission dioceses. As Margaret Mac Curtain asserts, “tensions came from within the [C]atholic structure of authority.” Popes had the power to withhold permission, but missionary bishops needed hospitals for women that would be run by the sisters. As well, laywomen and sisters lobbied the Vatican to obtain the medical training they knew they needed.64 Eventually the coalition of lay and religious personnel

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was successful: in 1936, with the publication of Constans ac Sedula, the pope lifted the centuries-old ban. Thus sisters as midwives, surgeons, and obstetricians came later to Africa. It was at this time that Mother Anna’s MMS and Marie Martin’s Medical Missionaries of Mary began training for health work in Africa and Asia.65 They had to fight to belong to the male world of medicine, but by the late 1930s they had succeeded. The role of physician or surgeon, which gave sisters medical authority, separated them from the religious authority of priests, and they won the respect of the patriarchal Church. As medical women with a distinct body of knowledge, they came to be held in high regard by priests and bishops. In Africa, spheres of influence developed between Protestants and Catholics and even among Catholic religious orders. Protestants were strongest in South Africa and the west coast, including western Nigeria. Catholics were more prominent in French Africa, eastern Nigeria, Tanganyika (Tanzania), Uganda (although strongly rivaled by Anglicans), and Belgian and Portuguese Africa. African Americans also worked as missionaries in Africa, especially in Liberia, with 115 serving in the latter part of the nineteenth century. Both white and black denominations such as the Baptists, Presbyterians, and the African Methodist Episcopal Church sponsored them.66 In British colonies, the focus of this study, colonial leaders encouraged many mission groups, with the result that there was great competition. Irish scholar Fiona Bateman notes that in the 1930s in Nigeria, “interreligious warfare” took precedence over any “spiritual or humanitarian interests.” To the Catholics, paganism, “Mohammedanism,” and Protestantism were all threats.67 By 1950, there were 23 million Christians on the African continent, 11 million of whom were Roman Catholics, 10 million Protestants, and 2 million independent church members. Of the Catholics, 3.5 million were in the Belgian Congo, 1 million in Uganda, and 700,000 in Tanganyika. Igboland in eastern Nigeria was also a Catholic stronghold.68

Contextualizing Changes in Mission after 1945 Decolonization and Independence The post–World War II years are important for Catholic missions because they were years of large cultural struggles for empowerment and Africanization of colonial institutions. European colonial rule over African

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countries was falling apart, and Africans were mobilizing to organize new governments, health care institutions, and education systems.69 In all of its colonies, the British government was moving to improve social services and educational opportunities with the goal of preparing Africans for eventual self-government, although independence came more quickly than the British expected. For this to be accomplished, a healthy, skilled, and educated populace was needed; hence, colonial, national, and mission leaders began focusing more on, among other things, training African women (and some men) as nurses.70 This crucial period of decolonization and independence also included civil wars and famines; growing anticolonial and anti-Christian movements; a repudiation of Western structures and institutions; the expansion of community-based primary health care centers; and the growth of Christianity, non-Christian religions, and indigenous forms of Christianity in Africa. Ghana became the first British colony to gain independence, in 1957. In 1960 Nigeria became independent, followed by Tanzania in 1961, Uganda in 1962, and many others in 1964. Other scholars have shown how, after World War II, new nationalist governments eagerly supported the biomedical model.71 Catholic sisters’ reconstruction of nursing and midwifery practice that reflected an appreciation of indigenous traditions would not come until the 1970s and 1980s. Before this, when they were expanding their work in Africa in the postwar period, nuns were fully committed to biomedical knowledge and were confident that it would be accepted. Indeed, this was a time of unparalleled optimism in medicine and science. As David S. Jones asserts, “the discoveries of wartime science and technology, especially penicillin and DDT, led many Americans to believe that medicine had achieved unprecedented efficacy.”72 Several diseases in sub-Saharan Africa were preventable, and by the 1950s sister physicians, nurses, and midwives could offer medical expertise and healing through antibiotics, expanded diagnostic technologies, and vaccinations that could conquer disease. Sisters had a clear understanding of the germ theory, the role of sanitation in disease prevention, and the positive outcomes of prenatal care for high-risk pregnant women. No reliable statistics on mortality rates are available from Africa in the early years; but in 1950, infant mortality was 284 per 1,000 live births (in the United States in 1950, it was 29.2). Life expectancy for African

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males in 1950 was thirty-five years of age and thirty-seven for females. Independence brought great expectations for the improvement of life, including eradication of poverty, illiteracy, and disease; and newly independent governments increased their focus on health, particularly maternal and infant care.73 Michael Worboys argues that “medicines [were] more readily transferred across cultures than other features of Western medicine.”74 Although initially Africans may have come to mission hospitals and clinics out of curiosity, by the 1960s and 1970s many had been exposed to modern medical practice for years.75

Increasing Ecumenism and Fidei Donum A growing worldwide ecumenism also affected mission practices. In 1948, the United Nations adopted the Universal Declaration of Human Rights, which included the freedom of religion, prohibition of discrimination on the grounds of race, religion, or sex, and the right to enjoy one’s own culture. In addition, what had started as an ecumenical movement for Protestants in 1910 at the Edinburgh World Mission Conference, which was interrupted by two world wars, resumed in 1948, when Protestant leaders established the World Council of Churches (WCC). As revolutionary politics in sub-Saharan Africa and the Cold War eroded the strength of Christian institutions, new transnational alliances occurred between Protestants and Catholics, and eventually they worked together through the WCC.76 Papal encyclicals in the 1950s also influenced Catholic missions.77 Pope Pius XII’s 1957 encyclical, Fidei Donum (On the Present Condition of the Catholic Missions, Especially in Africa), called for mission expansion to the African continent, and the pope emphasized the importance of training indigenous clergy. It came during the time when African independence movements were growing, and he was concerned that “blind nationalism” would lead the countries “into chaos or slavery.” He wrote, “The present situation in Africa, both social and political, requires that a carefully trained Catholic elite be formed at once from the multitudes already converted.”78

Expanding Education for Sisters As the sisters prepared for the mission field, they benefited from growing educational opportunities for women. In the United States, a process

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began in the 1950s with the Sister Formation Movement that focused on the need for more education, or formation, for specific works. Higher education for the sisters offered a route to more independent thinking not only about religion but also about social and political issues. The Sister Formation Movement exposed sisters to secular society, since much of their education took place in settings where nuns came in contact with diverse beliefs and people. Sisters qualified for credentials in nursing, medicine, teaching, and other professions. Inevitably, increased dialogue and questioning occurred among sisters about what heretofore had been considered unchanging truths that the Church hierarchy had taught.79 As a result, sisters began seeing themselves as individuals with human dignity instead of pawns of local bishops. In 1954 and again in 1956, the major superiors of the congregations met in regional conferences that culminated with the Conference of Major Superiors of Women (CMSW), an organization that dramatically enhanced American sisters’ status within the Catholic Church.80 While American sisters had to go to Europe for midwifery training, others could get medical degrees in both the United States and Ireland.81 In Ireland, university degree programs had gained popularity for sisters in the 1920s. Educational endeavors were enhanced when the MMM opened Our Lady of Lourdes Hospital in Drogheda, Ireland, in 1940, which became a training school for general nursing and a postgraduate hospital recognized by the Royal College of Obstetricians and Gynaecologists. In 1957 Our Lady of Lourdes officially became an International Medical Missionary Training Center.82 By the mid-twentieth century, then, a large group of female missioners had developed who could support themselves through their convents and earn respect and authority as experts in the mission field.83 For the American sisters, in particular, the Sister Formation Movement had encouraged them to take more control over their own lives. In 1962, women religious particularly were affected when Leon-Joseph Cardinal Suenens published The Nun in the World, which challenged them to reform their dress and living arrangements. In his view, this would allow them to better minister to others by becoming more integrated with the people they served. Although the Sister Formation Movement’s influence was lessening, by the 1960s sisters were acclimated to reform and were ready for further renewal.84

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Second Vatican Council Coinciding with changes in sisters’ lives and the political and cultural changes that came with African independence was the Second Vatican Council, or Vatican II, which met from 1962 to 1965. Whereas at the 1910 Edinburgh World Mission Conference Protestants had advocated for inculturation, inter-religious dialogue, justice issues, and Christian unity, these themes did not become widespread for Catholics until the Vatican II era.85 As early as 1909, Monsignor John Ryan, a priest on the faculty of Catholic University of America, had advocated for a just medical system and stated his claims in terms of human rights. He based them on religious principles espoused in Pope Leo XIII’s 1891 Rerum Novarum (Of New Things), the Church’s first social encyclical. Ryan’s claims were exceptional for his day, however.86 In 1928, in the encyclical Mortalium Animos (On Religious Unity), Pope Pius XI forbade ecumenical dialogue, which was growing at that time. It would be another thirty-four years before Pope John XXIII convened the Second Vatican Council and stated its goal as aggiornamento, to bring the Catholic Church up to date.87 The Church reversed many long-standing and heretofore uncompromising doctrinal policies. Hastings argues that this made “far easier” the “immeasurable adjustment which a very rigid church would have to undergo” in postcolonial sub-Saharan Africa. “In an at times almost unbelievable way the most unbending of positions were indeed enthusiastically bent.”88 This “religious earthquake,” as Philip Gleason calls it, was a pivotal event for Catholics all over the world as it sought greater engagement with others.89 Among those most deeply affected were women in religious life, including the missioners in this study.90 Women religious were not permitted to contribute to most Vatican Council meetings, but they were allowed greater influence on the commission that produced Gaudium et Spes (Pastoral Constitution on the Church in the Modern World, 1965).91 In calling for increased ecumenical dialogue and promotion of human rights and social justice, it encouraged sisters to redirect their missions.92 Dignitatis Humanae (Declaration on Religious Freedom, 1965) acknowledged the human right to religious liberty for all people and thus accepted the idea that salvation could occur outside the Catholic Church.93 The Council’s Ad Gentes (On the Mission Activity of the Church, 1965) was

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particularly influential for missions, because it emphasized a greater appreciation of other cultures and solidarity with the local people. In doing so, it strongly prohibited proselytizing that forced people to accept a faith they did not want. Rather than missionaries adopting the idea that they must convert others whose paths were guided by Satan, they were to enter into dialogue with other religions.94 Thus, while Fidei Donum in the 1950s emphasized planting the Church as the major goal, this vision changed in the 1960s. The Council’s Perfectae Caritatis (Decree on the Adaptation and Renewal of Religious Life, 1965) was especially instructive for sisters in that it called on them to reevaluate their missions by studying their original founders’ motivations for work.95 Sisters had been questioning their missions anyway, especially those in international mission orders. On the eve of the Council, for example, political independence for the former African colonies and their desire to be their own agents posed huge dilemmas for missionaries who had previously acquiesced to the colonial agenda. As well, economic disparities between the Global North and South were growing, and sisters’ large institutions had evolved to meet mainly middleclass needs rather than those of the poor. Before the Council, like other Catholics, sisters deemed that the main reason for contact with Protestants and other religions was to convert them. Nursing the sick had been a means to help the Catholic Church grow. Now the Church emphasized its place in the larger world, and sisters acknowledged that their charitable works should be complemented by actions for social justice.96 Women religious all over the world held special chapters, or meetings of representative members, to rewrite their constitutions to reflect greater engagement with the modern world. Significantly, this included a questioning of their long-standing goals of building institutions, and it involved placing a greater emphasis on eliminating the root causes of poverty.97 Many of the Irish congregations adapted slowly, because they had been indoctrinated to “blind obedience” since they entered their religious congregations.98 Others accepted the mandate with enthusiasm, and the American sisters did so as well. Another significant text of Vatican II was Lumen Gentium (Dogmatic Constitution on the Church, 1964), which proclaimed the Church as the “people of God.” This change undermined the very foundation of sisters’

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identity because they and the clergy were no longer seen as “holier” than the laity. Rather, every Catholic could be holy. This loss of identity was problematic for some sisters, and their numbers began decreasing after Vatican II.99 Some left their orders because they found the life unfulfilling, while others objected to oppressive male authorities. For some, renewal came too fast, while for others it was not fast enough. Still others discovered they were not called to the religious life in the first place, while some realized they could be ministers as laywomen rather than as religious. And some sisters who had objected to revisions left their orders for more traditional, contemplative orders.100 For those sisters who stayed, other papal encyclicals were important influences on their mission strategies. In 1967, Pope Paul VI issued Populorum Progressio (On the Development of Peoples), which advocated for all people to have an increased standard of living.101 That same year, in his Africae Terrarum (The African Land), he spoke positively about African traditions and spiritual values.102 Another document was Paul VI’s 1975 Evangelii Nuntiandi (Evangelization in the Modern World), in which Catholic understandings of evangelization expanded to focus on the need for ecumenism in response to a variety of contexts and needs.103 And greater dialogue with others did occur. Commissions of popes and Anglican leaders expressed common ground and restoration of unity at several meetings in the 1960s and 1970s.104

The American Civil Rights Movement Other circumstances outside their convent walls affected the American Catholic sisters in the 1960s. As social and religious changes continued to disrupt their ideas about their work and their personal and religious identities, many nuns increasingly participated in the civil rights movement. Amy Koehlinger analyzes how sisters abandoned works that historically had been a part of the American Catholic apostolate and instead participated in programs to promote racial justice. They marched at Selma, Alabama, and worked in schools and housing projects in urban cities.105 In 1967, when Sister M. Charles Borromeo asked, “Can sisters be relevant in the modern world?” in her classic book, The New Nuns, her answer was yes, by becoming “signs of hope and joy to the poor, and signs of scandal to the rich.”106

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African Theology Political changes all over the world also influenced new theologies of liberation. In 1968, many nuns and priests were influenced by Latin American bishops who called for liberation from unjust economic, political, or social conditions through a liberation theology; but, because of its Marxist connotations, eventually it drew the ire of the Vatican. At the same time, contemporary African theologies such as Africanization and liberation became popular. Discussions on Africanization had begun in African theological circles in the 1950s and 1960s at a time when independence became a reality for many African countries. The Final Communiqué of the Pan-African Conference of Third World Theologians in 1977 in Accra, Ghana, demanded that “African theology must be contextual,” that it must take into account the African situation. Africanization focused on cultural liberation and enhancing African values, that is, the necessity of inculturation. African theology must also be “liberation theology,” one that sees “the need to be liberated from socio-economic exploitation.” Thereafter, it became a pressing agenda among both Catholic and Protestant missionaries to make Christianity relevant in Africa.107 In 1969, Paul VI became the first pope to visit Africa, when he spoke to the Pan African meeting of Roman Catholic bishops in Uganda and asserted that African Christians should adapt the faith to their own spiritual needs based on African cultural realities. Yet disagreements occurred between African bishops and the pope, who feared the Africans were going beyond Catholic dogma. The Ecumenical Association of Third World Theologians (EATWOT) met in 1976 and the Ecumenical Association of African Theologians (EAAT) in 1977, each of which expressed uncertainties around official Catholic policy. Ghanaian Methodist theologian Kwesi Dickson asserts that Catholic policy after Vatican II was still “exclusivist” in that it was uncomfortable with “far-reaching developments, thus stopping short of a committed engagement with other religions.” Nevertheless, “The truth of the matter is that of the historic churches whose missionaries went out to countries in the Third World, it is the Catholic church more than any other that has repeatedly considered . . . how best to present the gospel to others. Outside the Catholic church official pronouncements of this kind are not easy to find— certainly not in such concentration—in contemporary times.”108

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Many issues thus combined to radically change the concept of Catholic mission, including sisters’ own renewal processes, social and political changes in African societies, race relations, and new church theologies. By the late 1960s, energized by Vatican II reforms and with a new self-confidence, Catholics had large numbers of priests and sisters, many of whom were trained professionals who could be transferred to areas of need; centralized coordination from Rome; and highly organized financial support. For example, American missioners numbered 781 in 1960, and they peaked at 1,229 in 1973.109 The Catholic Medical Mission Board, established in New York in the early twentieth century, supported Catholic missions all over the world by sending large quantities of medicines, bandages, dressings, and instruments. It also promoted scholarships for the education of indigenous doctors and nurses, helped establish schools of nursing in mission areas, and supported salaries of mission personnel.110 By contrast, Protestant mission hospitals were most active from about 1880 to 1960.111 By the 1970s, Protestants were moving toward a moratorium on European missionaries at the same time that Islam was expanding in Africa and African independent churches were growing. Yet Catholic missions remained strong. Although they did so later than the Protestants, Catholics were taking on more social issues while also translating scriptures and the liturgy into vernacular languages.112

Gender, Religion, and Transnational Encounters Dana Robert has called attention to the connections among women’s rights and medical care by asserting that both Protestant and Catholic women missionaries worked to improve women’s well-being.113 In the United States, the Catholic hospital system that began in the late nineteenth century was primarily the work of Catholic sisters. Secular women also established hospitals to provide opportunities for women to join the medical profession. Women justified their position by working in pediatrics, public health, and obstetrics. And both lay and religious women were increasingly active in health work for women and children in Ireland in the nineteenth century and especially after World War I.114 Sisters’ work in this area can lend insight into debates over gendered networks and how women worked within and also challenged barriers that

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decolonization and dictatorships created. In West Africa, where a Muslim population predominated, sisters rather than missionary priests were allowed to work with Muslim women. Although some feminist scholars criticize colonial nurses’ intervention in indigenous women’s reproductive lives, arguing that it brought about a loss of local knowledge,115 others see this work as meeting women’s needs when no other policies were available for them.116 Mission records abound with stories of how sisters fiercely battled to save the lives of twin babies, who were feared by some Africans, and this also meant saving the life of the mother.117 Many studies reveal different interpretations on how Western mission women shaped African women’s lives.118 One includes that of liberation through the provision of education and professional opportunities to women. In the former British colonies, nursing and midwifery (and for a few, medicine) were fields in which African women could get a postsecondary education.119 Women could be self-sufficient in their own hospitals. In this way, religion served an instrumental purpose—that of acquiring marketable skills at mission schools and schools of nursing. If they chose to enter religious communities, they could do meaningful work; yet in a society such as Nigeria where women were supposed to marry and have children, many women who opted for celibacy had to struggle with parents who tried to prevent them from entering convents.120 On the other end is the interpretation that the Church mistreated women. Ogwu Oju writes, “There is a myth in Christian circles that the church brought liberation to the African woman. . . . What actual difference has Christianity made for women, other than its attempt to foist the image of a European middle-class housewife on an African that had no middle-class that earned salaries or lived on investments?” Another writes, “It was the potent combination of Catholicism and the Ibo tradition that sealed our fate. As if being Ibo was not bad enough, we had to be Catholic also; one finished what the other had started in eroding whatever pride we might have had in our womanhood.”121 Yet another interpretation is that white sisters brought with them a sense of religious superiority, and indeed, some African women complained of intimidating and humiliating treatments. When white nuns and bishops established separate black women’s religious communities, they may have been culturally sensitive; or it might have been a sign of racial superiority.122

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Yet the wide range of experiences that missioners encountered in such culturally diverse areas as sub-Saharan Africa cannot be viewed in any binary fashion. Even as American and European missioners were influenced by prevailing worldviews and religious ideas of the Global North, they confronted much more complex situations with indigenous people who were not passive recipients of a foreign culture. As Mohamed Adhikari argues, regardless of elite or marginalized status, Africans were not impotent in shaping their identities “of who they are, how they have come to be who they are, and how they relate to others.”123 Africans consciously worked to achieve their own goals. They had specific political, social, and economic objectives as they engaged with Western missionaries, and they were selective in what they took. For example, one chief welcomed the MMS’s new hospital in Ghana in 1948 by focusing not on the religion the sisters brought but the medical services they could offer.124 African practitioners of biomedicine and nursing (many of whom were Catholic sisters themselves) also influenced its cultural translation. Other examples in this book will demonstrate how Africans exercised agency as partners, colleagues, or resistors.

Catholic Intercession in Sub-Saharan African Health Care As Megan Vaughan and others have pointed out, as an influence on the global scene missionaries have not been entirely benevolent. Indeed, throughout most of its history, the Catholic Church’s transnational encounters secured important alliances with kings, presidents, and builders of empires to secure its religious influence.125 Catholic missionaries were also instrumental in the colonial scramble in Africa in the late nineteenth and early twentieth centuries when they established Catholic schools and cooperated with European powers from the beginning.126 At the same time, most colonial governments wanted missionaries in their territories because they would provide needed services in the form of schools and hospitals. In addition, in the early twentieth century the British expelled French missionaries from Africa because they wanted English speakers, and they brought in Irish and Americans. Indeed, the English language was a key factor in attracting Africans to Catholic schools, because it was the language used in business transactions.127 As

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Nicholas Omenka asserts, “Cooperation between the Government and the Missions was, to a large extent, a marriage of convenience. Desirous of a healthy economy in the colony, the Government endeavored to ensure the existence of good and efficient schools. The Missions, for their part, needed the schools in the fulfillment of their evangelical ideals.”128 Although they spread their own religious, medical, and professional ideas to other populations, sisters had faith in local people’s capacities that other Westerners often did not have. The nuns in this study worked primarily among the poor, and they learned the languages of the people. By 1985, they were linking their service to God to eliminating root causes of poverty. Many also partnered with indigenous medical practitioners who had regained prestige after independence as an expression of cultural nationalism.129

Maryknoll Sisters In 1912, as the foreign mission campaign was expanding in the United States, a new Catholic religious congregation was established: the Foreign Mission Sisters of St. Dominic, or Maryknoll Sisters, under the leadership of Sister Mary Joseph Rogers. No American-based Catholic women’s religious congregation for overseas missions had existed until then. Sister Mary Joseph was raised Catholic but rather than attending a traditional Catholic school, she went to Smith College, an institution pervaded by a Protestant ethos. There she witnessed first-hand the Protestant missionary enthusiasm that was evident in many American colleges of the early twentieth century. Having lived and worked with Protestants, she was comfortable with religious pluralism. She also saw a specific role for Catholic women in the world because of segregation policies for women in other cultures. Under her leadership, the Maryknolls became nurses, catechists, and teachers, which fit in well with Catholic theology that emphasized women’s roles in the domestic realm. Some also became physicians, such as Sister Elizabeth Hirschboeck who began practicing in Korea in 1931, although not as a surgeon.130 When Rome officially approved the Maryknoll Sisters as a religious congregation in 1920, they began their overseas expansion to Korea, China, and the Philippines. That decade saw an increasing internationalization of the community, as sisters entered not only from the Asian

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countries but also from Europe, Canada, and Trinidad. In 1945, Maryknoll was one of the largest missionary congregations in the world, with 591 sisters in the community and nearly 100 others in training.131 The sisters went to Tanganyika (Tanzania) in 1948 and later to Kenya, Rhodesia (Zimbabwe), and Sudan. Like many of the American and European superiors of congregations, Sister Mary Joseph took on the task of visiting the different missions all over the world. This link helped each of the leaders to see what sisters were experiencing as they attempted to immerse themselves in their local cultures.132

Medical Mission Sisters Mother Anna, the MMS founder, was born in Austria but, at the encouragement of Dr. Agnes McLaren, a Catholic convert and Scottish missionary to India, she trained as a medical doctor at University College, Cork. After she graduated in 1919, she worked for some years in India, where she became convinced that professionally trained medical women were needed for the care of the sick. She was especially interested in health care for Muslim women. In 1925, she founded the MMS in Washington, DC, which was formally made a religious congregation in 1941. The MMS initially concentrated their mission work in India. Although they planned to expand to other areas of need, World War II disrupted that move. Thus, it was not until 1947 that they first went to Ghana, and they also practiced in Uganda, Kenya, and South Africa. The sisters eventually established their motherhouse (the seat of authority for women’s religious orders) in Fox Chase, Pennsylvania. Soon after their arrival in Africa, the MMS began recruiting local African women into their congregation. By the 1960s, they had more than thirty women from several African countries. In 1980, seven hundred members from eighteen different countries worked in five continents and thirty-three countries.133 In their work, the sisters were aided by Catholic lay women who raised funds and provided organizational support.

Medical Missionaries of Mary Marie Martin, founder of the MMM in Nigeria in 1937, had been a Voluntary Aid Detachment nurse in World War I, and she saw what good

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nursing and medicine could do to relieve suffering. She first went to Calabar, Nigeria, in 1921 as a lay missionary after receiving training as a midwife in Ireland. She returned to her home in Ireland, where she found companions who could help her address health care needs. Then in 1937 she went back to Nigeria where she established a congregation, which broke with the earlier Irish mission tradition of founding schools. Sister Agnes Maria Essien and Sister Veronica Akpan, both nurses, were the first African-born women to join the MMM in 1953. Sister Veronica was the first Nigerian postulant and Sister Agnes the first African to train at the International Medical Missionary Training Center in Drogheda.134 According to their unique abilities, as the superior of the congregation saw them, the MMM trained in nursing, medicine, midwifery, pharmacy, dietetics, laboratory technology, radiology, accountancy, and medical records. In the mission field, they concentrated on leprosy and maternal and infant care, although many of their facilities eventually became general hospitals. In Nigeria, they were active in Ogoja, Calabar, Anua, Abakaliki, Abudu, and Afikpo. From there they spread to Malawi, Tanzania, Uganda, and Kenya. As with the MMS, they blended a biomedical model with their own understandings of religion. By 1962 this congregation had twenty-eight foundations across the world, with 415 sisters in Ireland, the United States, Africa, Asia, and Europe.135

Missionary Sisters of the Holy Rosary Bishop Joseph Shanahan, an Irish Holy Ghost priest and Vicar Apostolic of Southern Nigeria, established the Missionary Sisters of Our Lady of the Holy Rosary (Holy Rosary Sisters) in 1924 when Agnes Ryan, a medical doctor, and six other women entered the religious order in Killeshandra, Ireland. In January 1928, five Holy Rosary Sisters and two Dominican Sisters left for Calabar in eastern Nigeria, where, initially, their raison d’être was to evangelize through the school system and to civilize the women. Eventually they opened schools for girls, a college for women, orphanages, and after 1928, medical institutions. From 1928 to 1967, they ran eight general hospitals, thirty-eight rural maternity homes, and many dispensaries in Nigeria. Two of the hospitals had training schools for nurses.136 The Holy Rosary Sisters worked with many ethnic groups to train them as nurses and as sisters, especially the Igbo (or Ibo), a major group

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in southeast Nigeria that was particularly eager for European-style education. The nuns had been in Nigeria since 1928, but it was not until 1953 that they accepted the first Igbo woman, who trained as a teacher: Rose Agbasiere, who took the religious name of Sister Joseph Therese Agbasiere. She came to play an important role not only as a teacher but also as a relief worker when she ran a refugee camp in Owerri, Nigeria, during the country’s civil war. Between 1956 and 1970, eight other Igbo women entered: Catherine Asomugha, Adeline Eronini, Cecilia Ezeh, Noel Mary Ajaero, Therese Egwuonwu, Helen Onyiuke, Evangeline Odili, and Susan Mary Otuonye.137

Sisters of the Immaculate Heart of Mary, Mother of Christ As noted earlier, the IHMs began in 1937 in Nigeria. The congregation was led by Maria Anyogu and Clara Oranu, who became teachers.138 While the Holy Rosary Sisters trained the new congregation in their religious formation, Sisters Maria and Clara taught the Irish sisters the local language. Sister Maria received additional education in Ireland and became the first Nigerian superior of the IHMs. By 1957, there were four IHMs who had professed their final vows, thirty-eight sisters with temporary vows, fifteen novices, fifty postulants, and twenty-three women who aspired to join the congregation. They eventually spread to other areas of Africa, including Sierra Leone, Ghana, Kenya, and Algeria, where they were responsible for running numerous schools, maternity homes, clinics, and dispensaries.139

Comparisons of Women Religious To understand the work of women religious in medical missions, it is important to comprehend the cultural environment for the development of different women’s congregations. Mother Anna had established the MMS in America; and she, other women such as Dr. Agnes McLaren, and some priests were very active in lifting Rome’s restriction on nuns practicing as surgeons, obstetricians, and midwives. Mother Anna was part of an American Catholic Church in a country dominated by Protestantism, individualism, religious freedom, and democracy; and it had a long history of tensions with Rome. For more than two hundred years, American Catholics negotiated how to be both American and Catholic, and by the early

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twentieth century Catholics had assimilated much of American culture with its individualism and freedom of speech.140 In the mid-twentieth century, led by the CMSW, the number of sisters in the United States peaked. The Conference changed its name after Vatican II to the Leadership Conference of Women Religious, and by the 1970s it was calling for greater access to power while also championing the cause of the poor.141 The MMS and Maryknoll Sisters, among many others, were part of this widespread movement that witnessed sisters taking on the values of open deliberation and political involvement. In this way, as Jay P. Dolan aptly describes, they were “at odds with the authoritarian and hierarchical Roman model that [had] emerged in the early twentieth century.”142 Whereas in the United States separation of church and state was a founding principle, Ireland has always been more closely aligned with Rome. The authoritarian and hierarchical model that so bothered the American sisters was more influential in Ireland. The MMM and the Holy Rosary Sisters were part of a strict Irish Catholicism that affected their work in many ways. After Catholic Emancipation in 1829, when Catholics were finally allowed to sit in the Parliament at Westminster, the Catholic Church grew in confidence. Following the famine years of the 1840s and 1850s, an evangelical revival occurred in which female religious orders became a key component to the Church’s growth. Women’s congregations grew from approximately 120 in 1800 to 8,000 by 1900. Mary Peckham Magray argues that these “agents of the Catholic Church” played key roles in the transformation of the Church and Irish society. As the Catholic Church became more influential and preached strict discipline, obedience, and devotion, the population became more overtly devout.143 After Irish independence in 1921 and extending into the mid-twentieth century, the formidable power of the Irish Catholic Church has been very influential. Emmet Larkin asserts that the Church “is at one and the same time a political presence of no mean proportion in the ongoing institutional system, a social institution that permeates nearly every aspect of Irish life, and one of the most powerful economic corporations in the country.”144 Irish women were particularly active as migrants to the United States in the nineteenth century. For example, the Sisters of Mercy, founded by Catherine McAuley in Dublin in 1831, arrived in the United States in 1843 and followed the many immigrant laborers to Pittsburgh, where they

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established a hospital. Under the leadership of Sisters Frances Xavier Warde and Mary Agatha O’Brien, they incorporated Mercy Hospital in Chicago in 1852. Another group of Irish Sisters of Mercy under the direction of Mother Baptist Russell established St. Mary’s Hospital in San Francisco in 1854.145 They were followed by many others. After 1908, when the United States was no longer considered a mission field, the Irish Catholic Church extended its outreach to Asia, Latin America, and Africa. This gave them great influence on the world stage. Indeed, by 1939 three million Irish Catholics provided one-twelfth of all Catholic missionaries in territories dependent on the Congregation for the Propagation of the Faith in Rome. In 1957, more Irish sisters were in the field in Africa than any other European group.146 Their Irish motherhouses emphasized a strict obedience to Catholic authority, yet many priests and bishops were alarmed by these strong women and tried to control them in their dioceses. Although the Catholic Church disseminated a gender ideology that limited women’s ecclesiastic roles, Irish nuns were able to exercise considerable authority in shaping their own religious communities and the people with whom they worked, and the Catholic Church increasingly embraced their labor.147 In summary, sisters’ work in sub-Saharan Africa after World War II complicates traditional narratives of a divergence between health care and religion in women’s and gender history. I also refute the assumption that religion and modernity oppose one another. Catholic sisters, the most traditional of women, practiced within the modernization of their fields, and the roles of science and technology were essential to their work.148 Inspired by their Christian calling and a strong sense of purpose, they wanted to make a difference in the world by moving beyond the domestic realm. They arrived in Africa with the full arsenal of their Christian faith and their own biomedically trained physicians, nurses, and midwives. Although somewhat ethnocentric and accustomed to patriarchy initially,149 over the last half of the twentieth century the sisters developed a greater understanding of diverse populations. In the process, their medical and nursing work intersected with critical social, political, and cultural debates in sub-Saharan Africa that continue today: debates about the role of women in their local societies, the relationship of women to the nursing and medical professions and to the Catholic

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Church, the obligations countries have to provide care for their citizens, and the role of women in human rights. The following chapters focus on themes of the evolving nature of mission and health care; the ways in which women crossed national, geographic, gendered, and religious borders; and the meaning of transnationalism itself. How the sisters navigated the cross-currents of social, political, and religious change to influence health care will be emphasized, along with unique experiences of specific congregations. While some of their actions resulted in expulsion from the country, others led to sustained projects.

2 Nursing, Medicine, and Mission in Ghana

In 1955 the government of the Gold Coast (later, Ghana) under Prime Minister Kwame Nkrumah endorsed the Report of the Commission of Enquiry into the Health Needs of the Gold Coast that noted that nurses were “the greatest contributory factor to improvement of the health services. . . . It cannot be said too often that until the number of nurses is adequate the extension of facilities in the curative field and to some extent in the preventive field will be of little or no value.” It also endorsed “enlisting the aid of missionary societies and other voluntary agencies in the provision of health facilities.”1 In 1957, Ghana became the first subSaharan African country to obtain independence from colonial rule. Nkrumah made his perspective on health and education evident from the beginning. In December 1957, he broadcast to the nation: “We shall measure our progress by the improvement in the health of our people; by the number of children in school, and by the quality of their education; by the availability of water and electricity in our towns and villages, and by the happiness which our people take in being able to manage their own affairs.”2 This statement connected health with the nation, and to Nkrumah, good health was a means to self-sufficiency. Afterward, government leaders expanded local health centers in order to rejuvenate their country.3 Significantly, this was the same year that Pope Pius XII had proclaimed Fidei Donum, which called for an expanded mission to Africa. This chapter situates the work of the Society of Catholic Medical Missionaries, or the Medical Mission Sisters (MMS), in the Gold Coast at 32

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the crossroads of colonial and postcolonial national projects to increase health care facilities and nursing personnel. Ghana is used as a case study to examine transnational collaborations and conflicts that resulted among Catholic missions, the British, and Ghanaians at the institutional level, when, after World War II, nuns started their hospitals and schools of nursing. By looking at the work of the MMS in Berekum, Ghana, larger historical questions can be examined about women’s roles in the development of acute and primary health care systems; the hierarchies, cooperative ventures, and tensions that occurred within these institutions; and the ways in which the participants crossed national, gendered, and religious boundaries.4 As part of the British colonial policy of indirect rule, local chiefs had to request or give permission for a mission hospital to be built in their regions. In 1948, at the request of Chief Nana Yiadom Boakye Awusu of Berekum, Gold Coast, three MMS arrived to open a dispensary for medical, maternal, and child health care. On April 26 of that year, the elders of the Traditional Council officially welcomed the sisters, and the people themselves greeted them two days later.5 Support from local rulers was essential; they granted not only land for the development of hospitals and schools but also the personnel to construct them. Berekum is located in the eastern region, 30 kilometers west of Sunyani, the regional capital of the Brong-Ahafo area. According to oral tradition, different groups of the Akans trace their beginnings to the Bono Kingdom in this rural area.6 When the MMS established Holy Family Hospital in Berekum, they worked with many of the Bono. At the time of its opening, the only health facility nearby was the government institution at Sunyani.

Background: Ghanaian Medical and Nursing Development The MMS built on a public health care system that had begun in the 1800s, probably introduced by European traders. According to Stephen Addae, during an expedition to the interior of the Gold Coast in 1817, a British medical doctor treated Ashantis in the persons of the king and his household, nonroyals, and slaves. Addae asserts, “The readiness and eagerness of the Ashantis to seek medical assistance from the British mission is a testimony to the supposition that modern medicine had already made an

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important and favorable impression in Ashanti by 1800 or earlier.”7 Historians provide conflicting information about the first hospital in Ghana. S. N. Otoo, a minister of health in Ghana in the 1960s, states that one was built in the Cape Coast in 1868, whereas Addae places it in Accra in 1878. Regardless, others soon followed, mainly along the coast. Although hospitals were segregated between Ghanaians and Europeans, it was at this time that indigenous people first had access to European health facilities, for which they paid a nominal fee. In 1899 the first European nurses arrived and provided systematized training for some indigenous pupils, and a health visiting program began. Korle Bu Teaching Hospital was established in 1923 as a general hospital specifically to meet the needs of the indigenous population.8 From 1920 to 1930, medical services to local populations grew as the British colonial government doubled its annual medical expenditures, and hospital beds increased tenfold. Maternal and infant welfare centers grew, and they utilized African and European voluntary workers to integrate acute and preventive measures through home visits and assistance in maternity hospitals. The colonial government also built a government hospital at Kumasi. The Great Depression, however, affected government spending; no hospital was built between 1930 and 1945 and some existing hospitals closed. Although a Unified Colonial Medical Service was established in 1934, excessive overcrowding occurred in the available public health facilities, and sanitary standards deteriorated.9 By 1946 the new colonial governor had ended hospital segregation, and when the MMS arrived in 1948, the government was beginning another hospital building program and expanding rural clinics. Thus, reducing mortality and prolonging human life was not only the sisters’ goal but also the aim of the government. When the first Ghanaian government took control in 1951, it inherited a medical system that was primarily centered in the south of the country and was chronically short of hospital beds and physicians. The population-bed ratio was 1:1,500 in the entire country. Morbidity and mortality rates, including maternal and infant mortality, were high, and life expectancy averaged only forty years. As part of Nkrumah’s goal to reform the health care system, the government accepted the Maude Commission’s 1952 report to expand health centers and to enlist missionary societies for help. By 1953 the colonial medical

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department had evolved into the Ministry of Health headed by a Ghanaian.10 Between 1951 and 1960, beds in government hospitals grew from 1,878 to 2,354; and as a result of the Maude Commission and the Report of the Commission of Enquiry endorsements, missions increased from 132 to 1,494.11 In addition to Holy Family Hospital, Berekum, the MMS established Holy Family Hospital in Techiman in 1954. The government built Kokofu Leprosarium in 1956 and collaborated with the MMS who administered it. In 1960, Nkrumah became president of the Republic of Ghana, and by then the number of smaller government health centers had increased from three to twenty-three, with many others under construction.12

Case Study: Holy Family Hospital, Berekum The planning for Holy Family Hospital began in 1935 when the Ashantis of Berekum negotiated with the local Catholic diocese to build a house and dispensary in the bush area about 100 miles southeast of Kumasi. World War II interrupted the plans, however, and the sisters could not come until 1948. When Sister Margaret Mary van Agtmael, a nurse midwife, Sister Paula D’Errico, a registered nurse, and Sister Raphael Devane, a registered pharmacist, arrived, they had no electricity and a scarce water supply.13 Sister Paula recalled the sisters’ arrival in Berekum on April 14, 1948: “Banners were stretched across the road from end to end welcoming us to our new home . . . And there to meet and greet us was Nana Berekumhene, his elders, sub-chiefs,” and many of the local people from the surrounding area, all dressed in “festive regalia.” Within twenty-four hours, the sisters had delivered the first baby in their lavatory.14 In 1950, Sister Laetitia Flieger led the construction of Holy Family Hospital. Reflecting the patriarchal values of the local community, the populace as well as the chief wanted a male doctor, even though Mother Anna Dengel would have liked to have a woman. She secured the services of both when, in 1950, a married couple arrived as surgeons, and the sisters took responsibility for their salaries. Also at this time, the diocese deeded the land and the hospital buildings, for which the diocese had paid, to the MMS congregation.15 This meant that, thereafter, the financing of any expansions was the sisters’ responsibility.

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In order to practice, the sister nurses had to register with the Nursing Council in Ghana and also were recognized by the British Council of England and Wales. They worked to improve their facilities so that the hospital could accommodate more beds and larger patient populations.16 (See table 2.1.) For example, by 1953 the hospital had expanded to fortyeight beds; at the end of the year, the nuns had treated 1,802 inpatients. The sisters faced an increasing workload in their outpatient department as well, having seen 53,532 patients in 1953. There was an urgent need for more help, and at this point they added indigenous dispensary and clerical workers. Throughout this time, the sisters at Holy Family Hospital continually dealt with scarce water supplies, and well into the 1950s they hand-carried water to the hospital. Growth continued over the next twenty years. By 1985 Holy Family Hospital had 162 beds; inpatients had increased to 7,615, and outpatients to 96,719.17 One of the defining characteristics of Holy Family Hospital, like other Catholic hospitals where sisters were administrators, was the way in which religious and professional boundaries altered authority structures. It was difficult to attract and keep physicians, but sisters’ international presence allowed them to recruit doctors from the United States, the Philippines,

TABLE 2.1

Statistics of Holy Family Hospital, Berekum, 1953–1985 No. of inpatient

No. of

Year

No. of doctors

beds

No. of inpatients

outpatients

1953

2

48

1,802

53,532

1955

1

48

2,696

36,610

1960

2

84

2,904

43,267

1965

3

90

3,636

57,627

1970

5

91

4,693

85,563

1975

5

93

5,494

100,528

1980

6

131

8,126

156,921

1985

7

162

7,615

96,719

Source: Archives of the Medical Mission Sisters, Berekum, Ghana.

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the Netherlands, England, and Ireland. Because the sisters ran the hospital, however, secular physicians had limited control. In 1952, a sister writing to Mother Anna noted that the doctors “are a problem. . . . They said if they would never be in charge they would not want to stay. I pointed out that they were in charge of the medical side of the work and they say they are not.” Yet another issue was at stake. Ghanaians’ tradition was to die at home in their villages, and it was not unusual for family members to take their dying relatives out of the hospital. The sister added, When patients are about to die the people insist on taking them home. There are several reasons why and the doctor will not let them go. But the doctors are only in the ward a few minutes but the relatives pester the life out of the poor Sister all day, and too, the patients and their relatives have human rights. We do everything to keep them; we are just as anxious for their recovery as the doctors are, but as I told the doctors this is not a jail. We cannot keep them by force.18

In addition, when the physicians complained that they did not see all the patients, the nun asked them if they would like to be called every time a night case was admitted, or when patients came at other odd times. The physicians did not want any part of that.19 The sisters themselves were accustomed to hierarchical authority. Structures in the hospital were modeled on that of the Catholic Church, with a sister superior as head of the community who had control over administrative and nursing affairs. There was also a medical director for the hospital. While the sisters yielded medical authority to the doctors, the nuns also were to obey the authority of the sister administrator. At Holy Family Hospital, Sister Camillus Healy was the superior. She was a midwife, not a physician, yet as administrator even physicians were responsible to her. Although this could be a source of confusion, the sisters were still part of a pre-Vatican II Catholicism in which they did not question policy. Physicians did, and sometimes they took their complaints to the bishop rather than the sister superior.20 However, Mother Anna would have nothing of it. Responding to a bishop’s letter of August 28, 1957, she wrote: I showed your letter to Sister M. Leatitia whose remark was that the Doctor’s statements contain half-truths. This is just what I gathered

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when I was in Ghana. By presenting our side also we will have a more complete picture and come to a good understanding, I hope. May I therefore suggest that in the future that Doctors or any others who bring complaints or problems about us or the work to Your Excellency or to the priests, be asked to submit them in writing for presentation to us, and that they be ignored if they are not willing to do so. . . . I must say in the other missions we do not have this reportage problem. I wonder if it is something peculiar to Africa.21

Sisters expected to have control over administrative issues with minimal interference from physicians or bishops. In effect, Mother Anna told the bishop that his intervention was not helpful, and she stressed that anyone complaining should first deal directly with the sisters. She subtly called out his intervention as creating an awkward triangulation, which undermined the power and authority of the nuns. Showing finesse that she had learned over the years, she closed her letter tactfully: “I assure Your Excellency that instead of taking your remarks amiss, I am actually deeply grateful because there is nothing like being aware of misunderstandings, shortcomings, complaints, etc.”22 She was successful in obtaining the bishop’s cooperation, but she also made her request to the Medical Department. The bishop responded: You could hardly think, Rev. Mother, that this reportage is something peculiar to Africa; it is peculiar to me and the Medical Mission Sisters. In the archdiocese, and here with the other sisters, it is the other way round: the sisters report the Doctors (and one of them is a priest of our society and was put in the wrong too). But the Med. Mis. Sisters consider us “another firm” and went so far as to advise government officials: “We would appreciate, as previous requested, that the Med. Department contact us directly rather than the ecclesiastical authorities since we are responsible for the administration of the institutions.” My mistake is that I did not think that way; yet still in whatever hospital or house the sisters desire to think as part of this mission, I will not repudiate them.23

He wrote again five months later, “In particular you wish me to have nothing to do with your doctors. I have accepted all this.”24 The MMS were

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respectful to but not cowed by Catholic Church or medical hierarchies, and they had their own means of resistance. The bishop cooperated, albeit reluctantly. The best way to stabilize the medical staff was for the MMS to have their own sister doctors. This occurred in 1957 with the arrival of Sister Doctor Jane Gates. Sister Jane joined the MMS in 1945 and, after a formation period, became a full member of the congregation in 1948. She graduated from Georgetown University Medical School in 1955. For her residency, she rotated through various services, including a year’s surgical residency at Sacred Heart Hospital in Allentown, Pennsylvania, before becoming the first sister doctor assigned to Africa in 1957. In order to practice in Ghana, she had to submit a photocopy of her diploma to the government, and then she received a license. Sister doctors were not allowed to do private practice, which would have competed with the few indigenous physicians available.25 At that time, medical services at Holy Family Hospital organized into medical, surgical, obstetrics, gynecology, and pediatrics. Sister Jane commented on the doctor-patient relationship she had with the mothers whom she treated. These mothers were acutely attuned to the symptoms and peculiarities of the medical problems of themselves and their children. Although many delivered at home with the help of local midwives, Sister Jane noted, “It was uncanny how they knew when something was going to go wrong, and they would come and you would say, ‘Where did you have your other babies?’ ‘At home.’ Well somehow they just knew they had to come for this one.”26 An understanding of the local context includes the diseases the sisters treated that were endemic to sub-Saharan Africa. Malaria and diarrhea were common and were especially problematic in children. Sister Jane recalled the dignity of the mothers who carried their babies tied to their backs the first two years of life (figure 2.1). They had the greatest personal knowledge of their children and were the best ones to detect illnesses: Sometimes they came in saying there is something wrong with the baby’s chest, because they would pick the child up under the arms. It would scream because there was pressure on the chest and it would hurt so the baby would start crying. Or they would hear the baby’s tummy making all kinds of sound, and they would say “the

FIGURE 2.1. Mother and baby with Sister Paula D'Errico, Berekum, Ghana, some-

time in late 1950s or early 1960s. Used with permission of the Medical Mission Sisters, Acton, UK.

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worms are talking” because intestinal parasites were quite common. Sometimes mothers picked up roundworms that had exited the baby’s body and brought them to the hospital in a container. . . . I would say, “What are they saying?” [The mothers] were very good at imitating things. They would say, “It goes like this.” And then I would say, “Did you ever hear water running through a pipe?” “Yes.” “What does it sound like?” “Oh, the same.” And I would say, “I don’t think the worms are talking. Probably the child has worms but is it having loose stools?” And they would say, “Oh yes.” I would say, “that is everything moving inside trying to get out.”27

At other times the mother would say, “My baby has a stone in [his/her] stomach,” which she could feel, signifying an enlarged spleen from malaria.28 Clearly the patriarchal doctor-patient relationship involving the doctor making the diagnosis and the patient submitting, which was often seen in American and European hospitals at that time, was not common at Holy Family Hospital. Nurses and doctors worked with indigenous mothers who were well qualified to participate in decisions about diagnosis and care. When Sister Jane performed elective and emergency surgeries, the latter for obstructed labor or ectopic pregnancies, she had the help of indigenous workers whom the sisters trained as operating room technicians. Patients often had tried everything possible before they came to the hospital with an obstructed labor. The main deterrent was transportation, because if they lived at a distance they had to locate cars and drivers, and there were very few of both. Sister Jane left Berekum in 1962 to take over management of a Catholic hospital in Fort Portal, Uganda, and Sister Doctor Fernande Pelletier became medical director at Berekum. She hailed from Maine and was a graduate of Trinity College and Georgetown University Medical School in Washington, D.C.29 As they carried out their medical and nursing work, sisters had to project an image of scientific accomplishment to the general public. Photographs represented Ghanaian student nurses learning anatomy and physiology, thereby casting the school as a modern scientific endeavor. (See figure 2.2.) Yet nuns also saw themselves as spiritual agents of care,

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FIGURE 2.2. Anatomy class with Sister Alice Hanks, tutor, Berekum, Ghana, 1963.

Used with permission of the Medical Mission Sister, Fox Chase, Pennsylvania.

and they carried out Catholic rituals as additional means to fight illness.30 In January 1953, for example, the nuns held the Feast of the Holy Family, a liturgical celebration that follows Christmas. Building on the significance of the event, one sister described it as a “whole family” feast, literally, because they had numerous deliveries that day along with many admissions.31 Catholic patients could receive Holy Communion, but even nonCatholics in the mission compound could witness religious processions led by the nuns. In 1963, one sister described the following event: “We had quite a crowd as we started out from the church, processed down the road saying the rosary. . . . It really was a big crowd with ten or twelve flower girls and three of the nurses as May Queen and attendants. After the function the older members went in to see James and they recited some prayers and the choir sang for him.” The patient James had recently requested and received last rites from a priest. Showing the tensions Catholic patients had to face with family members who did not support their conversion to Catholicism, the writer also noted, “[James] is no longer afraid of his relatives. God is good, and we hope the rest will follow.”32 Priests also held religious classes for student nurses, and sisters celebrated holy days in the hospital compound. Showing the blend of science and

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medicine, sister nurses and their students worked in medical spaces that were decorated with crucifixes (figure 2.3), and they integrated religious ritual into the everyday world of the hospital. This distinguished Catholic hospitals from government and Protestant institutions.

FIGURE 2.3. Hanging an IV drip in room with crucifix, Uganda, 1968. Used with

permission of the Medical Mission Sisters, Fox Chase, Pennsylvania.

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I have argued elsewhere that caring for the sick and dying were important roles for sisters because it placed them in situations that linked the worldly and the divine. Provision of nursing and medical care meant more than just healing the body; caring, serving, and treating the poor, the sick, and the dying was a means by which sisters could participate in important and dramatic religious experiences, and this conferred on them a special mission. In their hospitals, nuns could do physical and spiritually important work for their patients. The Catholic hospital was a place for healing the body and soul, obtaining penance and salvation, and encountering religious women who professed vocations to serve the sick.33 The professional authority of sisters was enhanced by their distinct dress in their white habits. Although this created boundaries between them and the people they served, the habits also were a symbol of religious identity. (See figure 2.4.) Ghanaians had their own ways of contesting those boundaries if the sisters did not reflect sensitivity to cultural norms. In May 1961 mothers protested an MMS policy that restricted their visiting hours with their

FIGURE 2.4. Holy Family Hospital, Berekum, Ghana, taken approximately 1959. Used with permission of the Medical Mission Sisters, Acton, UK.

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children. They protected their own interests by choosing to go to other hospitals, sometimes walking more than forty miles to another facility. The MMS justified the policy, even though it made more work for them since they had to prepare formulas and feed the babies. They noted, “It has been a tremendous difference on the wards as far as peace, quiet, and cleanliness are concerned. We have a feeling that some of the mothers gave their children home remedies in hospital simultaneously with our treatment, causing untoward results as well as preventing a more rapid recovery.” Apparently government hospitals were enacting the same policy.34 Most important, to a Catholic sister order was essential in maintaining an efficient hospital. Yet the 1961 policy caused great conflicts and a significant drop in admissions, especially of children, in both the hospital and outpatient department. Tensions over the strict regulations also occurred among the sisters, as each held different ideas about discipline and order. Five months later one sister expressed her questions about the policy to her superior: “Are we here to have a nice clean, quiet pediatric ward with no patients in it? Or are we here to take care of the sick? I’m all for keeping up standards, but it seems to me that if we are not serving the purpose for which we came, then we shouldn’t remain relentless.” Because of the low census, the sisters had to cut costs significantly. They returned a number of items that they had overstocked, cut down on the number of aides, tried to economize with food, and sold their Jeep. They eventually changed the policy so that the mothers could stay with the children during the day but not at night, because the nuns would not let mothers sleep with the babies on the floor, which was the custom. Eventually the patient census came back up.35 At the same time that auxiliary nursing workers were staffing American hospitals due to increased patient loads, the employment of local nurses and assistants became the norm in the sisters’ hospitals and clinics in Ghana. When Sister Jane and later Sister Fernande went on “treks,” or trips to outlying villages to hold clinics, they relied on Ghanaian expertise. For example, a clinic at Drobo was administered by an experienced nurse, Therese Debets, another local nurse, and several aides.36 Miss Debets screened patients and prepared them to be seen by physicians when doctors came on Saturdays. When the physicians were not

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present, she had standing orders for treatments for fever, snake bites, injuries, and respiratory and gastrointestinal complaints. Her work in this area prevented many unnecessary medical complications that otherwise would have been seen in the Berekum hospital. Using her judgment, Miss Debets referred “problem” cases to the hospital, such as bleeding from pregnancy, obstructed labors, suspected ectopic pregnancies, urinary retention, fevers that did not respond to antimalarials, rigid abdomens, severe anemia, moderate to severe jaundice or diarrhea, and patients with high blood pressure. When necessary, then, Miss Debets’s work included diagnosis and treatment responsibilities that were not typical of a nurse’s scope of practice in the United States or Europe.37 Patients paid for their visits and medicines, ranging from two shillings for babies to eight shillings for adults. Since the clinic was self-supporting, the nuns could pay the Ghanaian staff, as well as provide for pharmaceutical purchases and upkeep.38 Thus the rural health care system that evolved relied on professional and nonprofessional personnel––American, European, and Ghanaian. Diagnosis was not restricted to physicians alone; rather, nurses and mothers also diagnosed and treated, while using their own judgment. As the nuns worked with poverty, high incidents of disease, and resource limitations, they did not fear lawsuits. The legal environment was very different from the United States and Europe: there was no malpractice insurance nor could anyone afford to sue. Few physicians were available to work in rural areas, and nurses, auxiliary workers, and mothers themselves filled in the gap. At the same time, while the influence of American and European sisters is acknowledged, the evidence here negates any image of victimized Ghanaian women. They had the capacity to influence events by choosing not to come to the hospital, and when that occurred the facility suffered financially.

Holy Family Hospital Nurse Training School Education of indigenous nursing students was based on a transnational exchange of knowledge during the colonial period, when European nurses laid the foundation of professional nursing in the Gold Coast based on the biomedical model. In early nursing programs, British nurses ran the wards

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and trained men, because local customs prohibited women from providing nursing care to strangers; besides, few girls received the primary and secondary education necessary to enroll in nurse training school. In addition, women were not attracted to a field that was considered menial work, had low salaries, and included caring for men who were the main patients in the hospital. This lasted until the 1940s, when customs began to change, and primary and secondary education for girls expanded so that women would be qualified to enter. In 1945 the government opened a nurse training school in Kumasi and established another in Accra in 1948.39 By then, although men continued to be admitted to nursing programs, women began their dominance in nursing.40 In discussing Ghanaian nursing, Christine Böhmig asserts that it was in the 1940s that “the training program was standardized and nursing turned into a typically female profession. The presentation of nurses as disciplined, obeying and patient caregivers for the sick and dying and their appearance in the clean white uniform displayed and conveyed the image of a good woman, morally integrated Christian and possibly a perfect wife. By this, nursing became an attractive profession and gained status.”41 Nurses in training eventually could obtain registration in the Gold Coast. This was a reflection of professionalization developments in Britain, where, since 1919, nurses had had to register with the state. In the 1940s, the colonial director of medical services, Dr. Balfour Kirk, developed a nursing curriculum and standards in the Gold Coast that were comparable to that of Britain. A Nurse Ordinance came into effect in 1946 and a Nurses Board in 1950 that was responsible for registration examinations. Two classes of nurses came into existence: the qualified registered nurse (QRN) from a three-year program that was based on apprenticeship training, and the state registered nurse (SRN) from a program with more classroom and clinical work. After completion of a three-year program and passing an examination, the SRN could register with the Nursing Council of England and Wales and be recognized both in the United Kingdom and the Gold Coast. The QRNs could also take an examination, but they entered their nursing programs with only a Middle School Certificate, whereas the SRNs were required to have a higher secondary education.42 Mission hospitals had a large role to play in training indigenous nurses. In 1953, the MMS began a nurse training school that followed a

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path similar to training in other countries, with the hospital playing an important role. In the United States, for example, successful hospitals had to have affiliated nursing schools so that students could staff the wards. Similar conditions occurred in Ghana. The QRN programs were the most numerous in the country, and the dire need for nurses increased their demand. Thus at Berekum, the sisters established a QRN program beginning initially with eight students. Yet students’ poor educational background soon became problematic. After a four-month training period, some could not pass the Government Test for Pupil Nurse Index, which had to be taken in English. The sisters continued to work to get the school approved by the Medical Department and received tentative approval on December 10, 1953.43 On January 11, 1954, the sisters enrolled seventeen students into their second class, three-fourths of whom were Catholic.44 Students obtained room, board, and uniforms, and they worked all shifts. A typical night would find them feeding a ward full of babies who had measles, dysentery, and malaria.45 Retention in the program became a problem, however, and events soon demonstrated that these nurses were not always willing to be compliant or obedient. Much quarreling between the older and younger students occurred, and on March 5, five student nurses quit. More bad news came on April 22 when the sisters received the results of the nurses’ entrance exams: all the students failed, as did two-thirds of the colonial candidates in other programs. To prepare the students academically, Sister Camillus, the superior of the hospital, began teaching them English and arithmetic before any nursing courses.46 In the meantime, the remaining students had opportunities to practice not only in the acute care hospital but also in a new maternity wing and the Drobo clinic. Sisters held capping ceremonies to enhance the students’ feelings that they belonged to the profession. Yet by mid-December, more students had left, some for maternity reasons, others because of difficulty in working with a Polish physician, and others, according to the sisters’ chronicler, because of “lack of stamina and stability they need to persevere. About 12–18 months seems to be their limit,” not the required three years.47 At the beginning of 1955, the sisters admitted another class of students, bringing the total number of enrolled students to eighteen. Yet the hospital chronicles reveal more grievances: soon complaints erupted about

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food and low student pay. In April 1955 many students walked out again, with only seven remaining. The sister superior offered to change both the food and the cook, but it appeared another factor was the cause, namely, discontent over not being able to pass the exams.48 The walk-outs of nurses occurred at a time when political unrest heightened as the country moved toward independence. Political struggles included industrial strikes and walk-outs and influenced nascent nationalist movements. In the midst of the Cold War, U.S. and Britisheducated Nkrumah had become the first Ghanaian prime minister in 1952. Nkrumah had been elected under the Convention People’s Party, and he had been reelected in 1954 and 1956. Nkrumah received his early education from Catholic missionaries, but by the 1950s he was inspired by antiimperialist, leftist ideology. He refrained from calls for outright revolution, however, and eventually had the tentative support of the British government; yet anticolonial feelings persisted throughout the country.49 Robberies of the sisters’ convent, doctors’ home, and hospital at Berekum became frequent occurrences.50 In addition, rumors circulated from various quarters, including former staff, that were critical of the school of nursing. The Medical Department became concerned and sent a nursing matron from Ashanti to inspect the school. The MMS, also concerned about the problems, sent one of their sisters to the Northern Territories to observe the management of a state-subsidized Catholic hospital run by another women’s religious order. Another sister went to Kumasi to observe the government-run nursing school.51 By January 28, 1956, Holy Family Hospital had a new class of students that brought the total number to twenty-two. The chronicler noted that rumors about the school’s quality would cease if they could “just get some [of the students] through the government exams.”52 Alas, on July 3, the sisters heard that none had passed the exams, which significantly affected the reputation of the school.53 On July 20, the nuns learned that the students, as a body, planned to leave at the end of the month. Because they had failed their exams, they feared the school would never be able to give them a recognized certificate to nurse, which would have conferred increased status and income. Sister Camillus expelled some of the “ring leaders” and encouraged others to retake the exams.54 However, the sisters had to begin hiring auxiliaries to make up for the nursing staff.

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Problems persisted throughout 1956. Students continued to leave, and those who stayed had little confidence in the school. To add to the problem, some students were heckled when they went into town, and one was slapped.55 A laborer whom Sister Paula had dismissed struck her in the face; someone tried to burn the dispensary files; and others pulled up twenty-five fence posts surrounding the mission compound.56 Throughout the region, nursing services were experiencing difficulties. Salaries remained low everywhere, and staffing was particularly affected when nurses married or became pregnant. According to Addae, in the 1950s more than 50 percent of the nurses in some hospitals would be away on maternity leave at any one time.57 Helen Sweet and Anne Digby have analyzed similar problems at a mission hospital in South Africa when black nurses went on strike in 1949. Shula Marks also details events in other South African nursing schools where food was a common complaint.58 The tensions that occurred at Berekum reveal the kinds of expectations Africans brought with them to their work and how far they were willing to go if their hopes were not met. On their part, the MMS raised educational standards. They changed the nursing school curriculum to accept a one-year pre-nursing group before the four-month candidate training period and the three-year general nursing course. To advertise the program, they made posters and mailed publicity notices to various schools in the Gold Coast and Togo.59 In 1957, the first sister tutor for the QRN program was Sister Catherine Shean, an experienced nurse midwife who had trained at the sisters’ Catholic Maternity Institute in Santa Fe, New Mexico. Sister Alice Hanks managed the school. (See figure 2.2.) The sisters based their curriculum on the Nursing Council of the Gold Coast syllabus. At the same time Sister Camillus was appointed to the Nurses Examining Board to become an examiner for other hospitals.60 In January 1957, the sisters admitted another group of students. This time they required instruction in English (the language of the state exams) and general science as part of the new curriculum.61 The Ministry of Health paid a visit in April and discussed the possibility of a government grant for the school. By December 10, prospects were improving with forty new potential students and more who came a few days later accompanied by a priest. When it came time for the seniors to take their oral and

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written exams in Kumasi in 1958, one of the nuns went with them to help them get accustomed to the set-up at Kumasi Central Hospital. On July 1, 1959, they heard from the national Nursing Board that all the students had passed.62 One reason for the increased passing rate was that the sisters recruited students with higher qualifications. They also set up extra support systems, and the passing rates for exams remained high. The first three graduates obtained the QRN in 1961, and they took jobs either at Berekum or another MMS hospital. Eventually seventy-nine women and ten men qualified as QRNs from 1957 to 1972. In 1968, the Ghanaian government terminated the QRN training program, and sisters at Holy Family Hospital phased theirs out by 1972. Because the school did not yet meet the requirements of an SRN program, the MMS started a two-year Enrolled Nursing (EN) Program in 1969 with nineteen students. It continued until 1983, when it was also phased out. By then, 289 nurses (222 females and 67 males) had trained as ENs. During this period the school recorded a 100 percent pass rate at the final state examinations.63 Candidates to the school of nursing had to be unmarried and were between seventeen and twenty-five years of age. Sisters made admission decisions after the candidate interviewed and took a written examination. Upon admission, students signed an agreement to serve as a nurse at any hospital or clinic in Ghana that the MMS ran, for at least two years after graduation. They did not pay for schooling but rather received stipends according to government scales, and by the 1960s they had their own living quarters next to the hospital. Working and class hours could not exceed forty-eight hours per week, with one day off each week and annual leaves of thirteen working days. Patient fees and donations from American or European agencies supplemented the school.64 It was equipped with posters, microscopes, apparatus for teaching medications, and other equipment. Voices of Ghanaian students, including how they transformed knowledge to meet their own needs, provide insight into their perceptions of healing. In 1964, students at Holy Family Hospital were asked to write down why they wanted to be a nurse. Composed for their sister teachers, many reflected the missionary ethos of wanting to serve God. Their responses also reveal the extent that student nurses themselves were

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translators of the biomedical message. They wanted to know more about disease causation; how to give medicines, how each worked, and which ones to give for specific diseases. They also wanted to be able to teach mothers about good hygiene, nutritious food, and the prevention of infectious disease. Many also thought nursing was a good opportunity to earn their own living. But for most, a spirit of nationalism had awakened in them as their country embarked on independence, and they were eager to serve the people. Like their teachers, they blamed mortality on many factors, including illness and malnutrition that affected the entire nation’s health. A typical response was, “As I am a nurse and can cure, the population won’t decrease.” Invariably, their motives for being nurses included curing the local populace of sickness. In this way, biomedical knowledge became a source for local health care so that the population would thrive.65 To supplement services to mothers and infants, under the direction of nurse midwife Sister Rosemary Smyth, the Midwifery School at Holy Family Hospital opened in 1964. Many of the Holy Family Hospital graduates, both with the QRN and EN, applied and were accepted. Upon completion of the program, students took the exam of the Nurses and Midwives Council for Ghana.66 In addition to training midwives, by 1966 the sisters were training Ghanaian men for laboratory positions at Holy Family Hospital. The program consisted of three years of study in areas such as chemistry and bacteriology, and students then took qualifying examinations in Accra for certification.67 Thus, in 1966 sisters awarded certificates to three groups: four graduate nurses, six qualified nurse midwives, and two laboratory technicians.68 At the ceremony, the graduate nurses recited the Nightingale pledge. This initiation rite was an old practice by members of guilds or professions, and it carried over into nursing schools all over the world. Florence Nightingale did not write the pledge and she was not a Catholic, but the pledge recited in her name held the promise that the graduate was “to pass my life in purity and to practice my profession faithfully,” to maintain confidentiality, to do no harm, and to devote him or herself to the patients’ welfare. This pledge signified a commitment, or a vocation, to help people in need; although it did not come from the Catholic Church, the knowledge it advocated and the behaviors it expected were easily transferable by the sisters, albeit in a Ghanaian setting.69

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Financing Projects I have noted elsewhere Catholic sisters’ expertise in financing their health care facilities in the United States,70 and their proficiency extended to Berekum. To secure funding to run the institutions, the sisters charged their patients fees. For their expansion projects, the MMS had a Development Department at the motherhouse in Fox Chase, Pennsylvania, and they hired a full-time grant writer. Indeed, a strong and efficient motherhouse was essential for the smooth and successful running of the sisters’ institutions. The sisters also cooperated with global agencies. They applied for funding to the German agency Misereor in 1967 to support the nursing program at Holy Family Hospital. This support included money to help build maternity and pediatric blocks, dining areas, upgraded nurses’ housing, and classrooms. The MMS congregation financed $86,000 or 25 percent, a German government’s grant furnished $200,000, and the Misereor loan provided $58,000. All loans were made to the MMS congregation in Fox Chase, which was responsible for repayment. To construct new buildings, the MMS also received funding from donor agencies from Belgium, the Netherlands, and the Catholic Medical Mission Board in New York. Grants allowed the MMS to build a ward for private patients, which brought in more income and covered costs for people who could not pay. As the years passed, sisters received government grants-in-aid for their hospitals that went for staff salaries. Crates of sample medications came from Philadelphia, and the nuns could also purchase supplies from the government stores in Kumasi.71 These transnational connections were crucial to the sisters’ success.

Staffing Issues Staffing was always an issue as sisters transferred to other facilities or replaced another who went on a needed vacation. It was not unusual for the sisters to get sick, either with hepatitis or malaria, common diseases in the region. Thus they always relied on student nurses and assistants who became essential to their work. One sister wrote, “The graduates are doing well. We really could not get on without them, and we count on them for the greater part of the ward supervision.”72 Figure 2.5 shows two assistants in the pharmacy at one of the MMS hospitals in Uganda.

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FIGURE 2.5. Sister Maria Hornung with pharmacy assistants in Uganda

hospital, 1966. Used with permission of the Medical Mission Sisters, Fox Chase, Pennsylvania.

One challenge that had to be faced when working with the Ghanaian government was in response to its 1960 Industrial Relations Act, which dictated that all civil servants had to be members of the Trade Union Congress (TUC).73 This included hospital employees at Holy Family Hospital. A sister began attending the union’s monthly meetings and noted, “It has been rather trying at times to have to go along with some of the requests from the head office of TUC, but in the end it is the more sensible thing to do.” As sisters dealt with issues such as pay increases and working conditions, negotiation was key: “To go along with them,” noted a sister, “and not compromise principles, to be able to get them to see and do things our way too, requires a lot of time and attention, but it is very essential that they know we are willing to go along with them. . . . And actually, when compared to similar organizations in other countries, what they ask in some instances are long overdue with regard to the worker.”74 Table 2.2 shows that between 1958 and 1966, the sisters employed from fifty-six to eighty lay employees; these figures probably included nurses as well as nursing aides and medical and laboratory assistants.75 The table also reveals an increasing number of patients, surgeries, and

TABLE 2.2

Personnel and Procedures at Holy Family Hospital, Berekum, 1958–1966 Total

Total

Total

% turnover of

Lay

Average

outpatients/ Total trek

surgeries/ deliveries/ Nursing

inpatients/day

yr.

yr.

yr.

students

patients/yr.

Midwifery students

Year

Sisters

lay workers

workers Total beds

1958

14

21%

69

72

44

50,632

525

555

10

1960

13

8%

74

84

56

43,267

717

624

13

1962

12

9%

56

84

54

37,098

950

587

44

1964

12

33%

68

90

88

43,542

46,253

980

622

53

7

1966

16

13%

80

106

108

46,220

52,495

900

608

62

13

Source: Archives of the Medical Mission Sisters, Berekum, Ghana.

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deliveries over the years. While the number of outpatients remained steady, inpatients more than doubled. Additional patients received care when sisters went on treks to outlying areas, with 52,495 people seen in 1966. The sisters’ health care enterprises simply could not function without local community workers to help staff them. At the same time, nuns did have issues with employees. Table 2.2 shows that, in 1964 the turnover rate of lay personnel was 33 percent, although this varied from year to year. While some Ghanaians expressed their complaints against the sisters and took specific actions, others played roles in conflict resolution between missioners and the people. Strikes continued, and often the MMS depended on the support of the local chief. At times he personally came to the hospital to negotiate with the employees. This mediation strategy was important to maintain his standing among the local populace. During one strike, however, the sisters notified the chief that they could not see patients that day because they had no staff. According to one sister, the chief soon arrived at the gate where people, including the striking employees, had congregated and he told them: “I don’t know whose idea it was to say that you weren’t going to work. . . . This is my town, this is my jurisdiction, and I am telling you if you aren’t back to work by noon today you can just pack up all your stuff and go live in some other town.”76 Obviously this is one version of the story; nevertheless, the workers returned. In the 1960s, as political issues intensified in Ghana and hospital workers became involved, local Catholic bishops established a policy that missioners could have nothing to do with politics. If workers wanted to develop a branch of the Convention People’s Party, the ruling and only legal political party at that time, they could not hold meetings during working hours or on hospital property. This policy continued throughout the sisters’ stay in Ghana.77

Increasing Transnational Collaborations The sisters were not alone in their commitment to health care. The Ghanaian government had recognized the worsening postcolonial situation and had invested three times as much money in 1960 and 1961 for health care facilities as it had ten years earlier. Utilization of government hospitals increased all over the country.78 An important secularizing

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threat came when the Ministry of Health became interested in working more closely with mission hospitals. In 1961, the minister of health called a meeting with hospital representatives from twenty-seven different missions, both Protestant and Catholic. The Catholic Church was vitally interested, since eighteen of the twenty-seven mission hospitals represented at the meeting were Catholic. The Ministry of Health proposal called for the provision of government aid as long as the hospitals agreed to work within the Ministry’s framework, which included financial accounting reports to the government. If missions opened in new areas, they had to be where the government saw the greatest need. Catholic leaders were concerned that, by accepting government aid, their independence would be threatened, since they would have to consent to more government regulation.79 Thus, with growing government involvement, all church hospitals became more united. In 1962 Sister Jane attended the Christian Medical Worker’s Conference, which consisted of mission representatives from both Protestant and Catholic organizations. Topics included “Understanding the African Personality” and “Cooperation with Government.” Each representative worried that, as the government was becoming more socialist, it would take over all the hospitals. This made it even more imperative that the missions train as many Ghanaians as possible. In crossing ecumenical boundaries before Vatican II concluded, Sister Jane commented about the meeting, “It was a wonderful experience. We were Catholic, Anglicans, Swiss Presbyterians, and Evangelical Presbyterians (American).”80 Even though Vatican II would have a great effect on MMS actions after 1965, the ecumenism that resulted in 1962 was largely in reaction to perceived threats from a secular government’s determination to gain more control over hospitals all over the country. The Ghanaian Ministry of Health did become more active in working with mission hospitals. In September 1965 the minister of health spoke to a group of Catholic and Protestant hospital leaders about the importance of mission hospitals and government facilities partnering together. This involved government aid, compliance with government standards for hospital fees, cooperation in training nurses and doing preventive work, and refraining from using the hospital in “pressing the patients to conform to their particular kind of religion.”81 Three months later, Sister Fernande,

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who by then was medical officer of Holy Family Hospital, attended a meeting of the National Medical Advisory Board of the National Catholic Secretariat. The group consisted of priests and sisters from Catholic hospitals across Ghana. They recommended that the advisory board, which would eventually have Protestant representation, be consulted by the Ministry of Health in the future.82 The National Catholic Secretariat responded to the minister of health that Catholics would fully participate in training nurses and doing preventive care, but other requests required more negotiation. In April 1966, the National Medical Advisory Board met again and worked out a specific memorandum that emphasized how Catholic hospitals were different from others: their work affected the whole person, physical and spiritual, body and soul; sisters were ready to go where others were not; and, marking a distinct change in rhetoric, the work of the Catholic hospital was not “a means of conversion.”83 In September 1966, the National Catholic Secretariat Department of Health, which consisted of seventeen sister doctors and nurses, five laypeople, and seven priests, continued the discussion of how to respect “Mohammedans, pagans, etc.” who were in their hospitals who might object to Catholic rituals.84 In carrying out traditional values of serving all in need, the challenge was how to be acceptable to the secular government and diverse populations while maintaining Catholic distinctiveness. By 1969, the Holy Family Hospital Governing Board consisted of representatives from the local Berekum community.85 Ongoing collaboration was essential in postcolonial Ghana, where there was a rapid succession of coups that alternated between civilian and military regimes. Nkrumah was overthrown in 1966, and other coups occurred in 1972 and 1979.86 The MMS followed the longstanding diocesan policy of not speaking out against the government or doing other activities to draw attention to themselves.87 As always, local Ghanaians were vitally important to the sisters’ success. Staffing was aided when the University of Ghana medical school, which had incorporated in 1969, sent medical students to do a clerkship in community health and surgical training at Holy Family Hospital. In the process, the mission hospital contributed to the education of black doctors. Medical students also went on treks with the sisters and a public health nurse to do children’s clinics. Also at this time, local

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volunteers received short courses on how to conduct village child welfare clinics. By then, the hospital offered training in auxiliary positions for operating room technicians and medical assistants, in addition to training nurses, midwives, anesthetists, and laboratory assistants.88

Reducing Maternal and Infant Mortality The health of mothers and children was a key focus of government and mission programs for health. Despite their efforts, in 1960 the infant mortality rate was 110 per 1,000 births, the stillbirth rate 60 per 1,000 births, and maternal mortality 10 per 1,000 deliveries.89 Over time, both the government and mission personnel encouraged women to obtain prenatal care and, for complicated pregnancies, to deliver in the hospital. The growth of maternity services also meant that the hospital needed midwives, and the sisters’ midwifery training program was crucial to staffing.90 Table 2.3 shows a sample of patients treated in the hospital in January 1961 and their obstetric histories. Analysis of data suggests that the majority of women in 1961 had delivered at home for their first babies. Many had already lost children either in childbirth or before the age of five. For one woman who came to the hospital for her eighth pregnancy, both the sister midwife and sister physician delivered the baby with the use of forceps. For one who had had three normal term deliveries at home, the sister midwife delivered. Reflecting an expansion of health clinics in the area, in 1965 sisters began recording whether or not expectant mothers had prenatal care that involved teaching about nutrition and safe pregnancies. Many of the women had anywhere from one to eight prenatal visits. Some expectant mothers had been referred from the sisters’ Drobo clinic. Yet prenatal care did not always lead to easy deliveries. One woman had five prenatal visits, probably to monitor her hypertension, and still arrived hypertensive and eclamptic. The difference was that she could get emergency care, and she and her baby survived. Data also reveal that most deliveries were spontaneous, and only a few Cesarean sections had to be done on women with prolonged labor. These records validate what Nancy Rose Hunt asserts about the Congo: that the arrival of Catholic nuns as midwives and physicians “permitted the hospitalization of childbearing.”91

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TABLE 2.3

Sample of Patients Treated at Holy Family Hospital, Berekum, January 1961 Patient

Comments

25-year-old female

4 normal term deliveries; 2 sets of twins; 1st set died; 2nd set, 1 alive, 1 dead.

27-year-old female

5 normal term deliveries; 2nd baby SB [stillborn]; 3rd abortion at 3 months.

25-year-old female

1st born lived for about an hour; 2nd twins, 1 lived 2 weeks only, 2nd died 1 year.

26-year-old female

7 normal term deliveries at home. All living. 1 abortion about 16 yrs. ago.

20-year-old female

2 normal term deliveries

20-year-old female

1st normal term delivery at home, 2nd normal term delivery at home, 3rd normal term delivery at home, 1 died during childhood.

36-year-old female

11 normal term deliveries at home. 6 dead, 5 living.

30-year-old female

1st delivery S.B.; 2nd delivery died age of 4 weeks; 6 normal deliveries A&W [alive & well].

22-year-old female

1st delivery Caesarean Section. Baby lived for 11 hrs. & died.

? aged female

4 A&W, 1 SB.

Source: Archives of the Medical Mission Sisters, Berekum, Ghana.

Catholic policies that encouraged safe childbearing fit in well with Ghanaian expectations that defined women by their abilities to bear children. Ghanaian women had an average of six to seven children during their reproductive years. By 1969, however, population growth was occurring as children were living longer, fertility rates were high, and the overall death rate was falling. The changing demographic prompted the Ghanaian government to issue a policy statement that called for lowering “the rate of population growth to manageable limits” through a voluntary family planning program.92 This involved contraceptive use and informing and persuading people of the benefits of family planning. At the same time, a

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two-year development plan continued to emphasize health promotion and reduction in mortality.93 Ghana became one of the first sub-Saharan African countries to adopt such a plan. Yet the policy contrasted sharply with the pro-natalist policy of the Catholic Church. In 1967, Pope Paul VI had issued Humanae Vitae, the encyclical that reemphasized the Church’s teaching against all methods of artificial contraception. At Berekum, sisters did not teach any form of artificial contraception but continued to work to make birth processes safer.94 By 1970, Ghanaian midwives were doing deliveries. Some may have been carrying out contracts that stipulated they work in the hospital for six months after they finished midwifery school, but others had significant experience. And with few gynecologists and obstetricians available, experienced midwives were much preferred to inexperienced physicians.95 At that time, more women were delivering their first babies at the hospital. Registries for 1974 showed that women were also increasingly coming to the hospital with histories of normal deliveries either at home or at the hospital.96 Women not only visited the clinics and hospitals but they also attended classes on childbirth and child care. All of these efforts succeeded in making prenatal care and trained assistance at delivery available to more women in the Berekum area. While it is difficult to quantify improved health outcomes in the region, it seems clear that lives were being saved, or, as one sister physician said, children did not return to the clinic with the same disease. As well, villagers commented to a sister in another setting, “No more of our women are dying in labor.”97

“Healing” Rather than “Medical” Mission As their institutions increasingly Africanized, the MMS enhanced their own knowledge of Ghanaian culture by attending concerts at the Institute of African Studies at the University of Ghana, reading articles about the local cocoa industry, and perusing magazines about higher education published by Ghana’s Ministry of Information and Broadcasting. They went beyond the listening and reading stage, however, when they engaged the Anglican Terry Waite to lead them as they reevaluated their medical mission work. Waite was especially instrumental in helping the sisters move toward greater intercultural formation.98

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In 1967, the MMS began their renewal discussions in the spirit of Vatican II and started experimenting with new forms of medical mission work. By then, Sister Jane, the first MMS doctor in Ghana, had been elected superior of the congregation. In early 1968, the MMS replaced their religious habits with lay attire. Their reexamination also included studying their founder’s original purpose for the congregation, revising the constitution, and restructuring the community to give attention to the signs of the times. This was not an easy time for any religious community, and some groups split as they tried to determine new directions for mission. The MMS were able to ward off major ruptures, but not before the Vatican intervened in 1972 by sending an apostolic visitor to monitor their chapter meetings. This was a huge blow, as it indicated lack of Vatican trust that the sisters could resolve their own difficulties. Sister Jane wrote a letter to the membership, indicating that “the hierarchical church does not understand what we are trying to do. But today, we are 700. How dedicated we are will come out in our answers” to the questioning by the apostolic visitor.99 The visitor observed the MMS at their Chapter meeting in 1973, when, after tense and difficult discussions, the sisters adopted a “Common Purpose”: to become an integral part of the people with whom they worked, to “seek out those who are more in need of healing, the critically broken members of society, those who are without resources and without power to help themselves.”100 Evangelism was about making the Church present in people’s lives. This change in mission was validated at the 1974 Central Assembly, when the sisters developed a report that prioritized being at the service of “oppressed groups.” This implied “that we do not support projects that perpetuate or reinforce the (unjust) system.”101 Afterward, the apostolic visitor’s official report was positive. Still, these self-directed sisters resented Vatican interference. They knew they were part of the Catholic Church and that the Vatican would be reviewing their work. Yet they were inclined to look within themselves to work out the details of their mission rather than thinking first about how the Vatican would expect them to handle specific situations. As they promoted their collective interests within broader Church structures, they were keenly aware that the Vatican Council had legitimated new experiments in mission. As long as the sisters were confident that they were carrying out the

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Vatican’s general edicts, they found ways to do what they wanted to do, all in good conscience. In 1973, the first Ghanaian physician joined the staff of Holy Family Hospital, and the MMS turned the facility over to the Sunyani diocese in 1975. In 1987 the Holy Family Hospital School of Nursing was elevated to the status of a college, with students training as SRNs. By then they were housed in a two-story building with four-bed cubicles and a capacity of a hundred female students. The men nurses stayed in the sisters’ old convent.102 Graduates were able to receive fully certified nursing qualifications, which provided career opportunities for both women and men. The days of beginning institutions were over, but the questioning continued. Was it right to impose strict rules on patients and visitors, or to deny a pregnant woman a nursing education? Over time, the sisters found justifications to simply ignore some of these regulations.103

3 Shifting Mission in Rural Tanzania

In 2012 Luis Gomes Sambo, regional director of the Africa Region of the World Health Organization (WHO), wrote, “Most countries in the Region inherited a colonial, European model of health care that was primarily intended for colonial administrators and expatriates, with separate or second class provision made—if at all—for Africans.”1 This statement was written from an international viewpoint, yet when one considers experiences in health care at the local level, a different picture can be seen. Small health care centers administered by Catholic sister nurses and physicians in Tanganyika (later, Tanzania) after World War II illustrate a transnational model of American Catholic women working with local Tanzanians, both Catholic and non-Catholic, in a health care delivery system that blended acute and preventive care. During the 1960s and 1970s, sisters continued their work in rural areas, but they drew on a renewed Catholic understanding of the Church as the people of God. This meant being “with” rather than doing “for” the local populace, and was a key shift in mission.2 This chapter focuses on the Foreign Mission Sisters of St. Dominic, or the Maryknoll Sisters, in north central Tanzania, who established dispensaries and maternal and child health care clinics during and after the colonial period. Whereas dispensaries were established in England and America in the late eighteenth century to provide care to the poor, in subSaharan Africa in the mid-twentieth century they often were the only health facilities in the region.3 The chapter serves as a lens through which to highlight conflicts and compromises that occurred as sisters and their 64

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Tanzanian coworkers navigated broader political, economic, and religious changes to influence health care at the local level. Sisters had to negotiate among social networks among families, deal with unreliable transportation systems, work out conflicts between their own and their patients’ interests, and eventually adapt their mission while still adhering to the structures of authority in the Catholic Church. The chapter supports Michael Jennings and Terence Ranger’s studies in colonial Tanzania, which reveal that mission clinics and hospitals provided a wide range of biomedical care as well as preventive services, especially for women and children.4 Like their Protestant counterparts, the Maryknoll Sisters did not work solely in curative care, yet colonial leaders continued to insist that missionaries did. Jennings provides a compelling explanation: it was the self-interests of the colonial state that led it to depict mission medicine as curative, since the state could then assert that mission medicine was inferior (i.e., not preventive) and therefore not worthy of state support through grants-in-aid. What resulted in Tanzania was a pluralistic healing environment in which mission medicine was one of many systems offered to Tanzanians. Missions brought an important biomedical presence, however, and they remained a critical factor in health care after independence, with the result that the new Tanzanian government supported funding their services.5 As in Ghana, African auxiliary personnel whom the nuns trained in Tanzania played key roles in the sisters’ clinics and dispensaries, and they were important in the translation of mission medicine to their local communities. Historians have explained this phenomenon in several ways. Whereas some see biomedicine and the use of African personnel as tools of empire, others view mission hospitals as sites of negotiation between Africans and Western practitioners.6 Through an examination of interactions between Maryknoll missioners and Tanzanians in rural dispensaries, clinics, and villages, this chapter reveals multiple forces that were in play in shaping the delivery and use of health care.

Background: Nursing and Medicine in Tanzania The first Protestant physician working through the Church Mission Society arrived in Tanganyika in 1877, and Catholic White Fathers

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established a hospital in 1888.7 Yet it was not until after World War II that biomedical health services expanded in the country. In 1948 four Maryknoll Sisters went to Kowak in the administrative region of Mara in the north central part of the country, where they opened a school, ran a dispensary, and did home visits. As in other countries, the Catholics developed their missionary work in specific areas. The Maryknolls competed not only with Protestants but also with other Catholics such as the Swiss and Italian Capuchins and the Holy Ghost Fathers, each in their own region of interest.8 Much of the Maryknolls’ delay in going to Africa was due to their concentration in Asia. In fact, they had been the most important American Catholic mission group in China until the Communist victory in 1949 led to the expulsion of most of them. When that happened, they began to accept new works in Latin America and Africa.9 Tanganyika had been a German colony since 1886 but became a British mandate after World War I and a trust territory of the United Nations, under British control, following World War II. At that time, the colonial government provided 4,300 hospital and dispensary beds, while missions accounted for another 2,000 beds. Yet doctors and nurses trained in the biomedical model were far fewer than required. In addition, as rural dispensaries grew, they did so in a scattered and uncoordinated fashion.10 In 1949, Dr. Eric Pridie, chief medical advisor to the Colonial Office, reviewed the medical policy in Tanganyika and acknowledged that preventive services were needed. Yet he also noted that they should not be at the expense of curative services because the people demanded curative medicine. Its popularity would then make preventive programs more acceptable. He recommended that the government continue to use existing nongovernment organizations, including the missions, and that more Africans be trained as physicians, nurses, midwives, medical assistants, and rural aids. The report also called for more rural health services that provided both cure and prevention, which would serve as a means of health education at the village level.11 The Maryknoll Sisters’ dispensary at Kowak was one means of reaching this national goal to expand care to rural areas. Still, evangelization was central to their work from the beginning. A health care ministry facilitated conversions and the spread of Catholicism, and this pre-Vatican II strategy

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permeated the sisters’ activities in the early years. Health care also was a means to carry out Christian charity in a concrete way: dispensaries and clinics alleviated many of the physical ills of people in the local community.12

Case Study: Kowak Mission Sister Margaret Rose Winkelmann, one of the first sisters to arrive at Kowak, recalled that when the bishop came to their New York convent to talk about Tanganyika, “Many of us were ready to go with no hesitation.” Indeed, “it was something to dream about.” Anglicans predominated in the southeast, and in 1948 Rome gave permission for the sisters to go to the north central area.13 The Maryknoll sisters expanded to other sites, but the history of the Kowak mission will be the focus here, since it had the largest single group of Maryknoll medical and nursing personnel in the country. Most sister nurses who went to Tanzania over the years stayed at Kowak for initial orientation. (See figure 3.1.) When the sisters first arrived, several young Tanganyikan women were living at the mission under the guidance of a German White Father

FIGURE 3.1. Sister Joan Michel

Kirsch with young boy, c. 1950s. MSA/Images/Tanzania/ Kowak/Kirsch, Box 1, folder 31. Used with permission of the Maryknoll Mission Archives, Maryknoll, New York. Sister Joan was one of the pioneer Maryknoll sisters who went to Tanzania with Sisters M. Stanislaus Cannon, Margaret Rose Winkelmann, and Catharine Maureen Bowes. Sister Joan did pastoral work in Kowak from 1949 to 1957.

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who was preparing them for a religious congregation. He soon turned the direction of their religious formation over to the Maryknoll Sisters, and the young women became the nucleus of the Immaculate Heart Sisters of Africa. One was Sister Bernadetta Abel, and she and the other women introduced the Maryknoll Sisters to the Kowak community. As Sister Margaret Rose recalled: “I don’t know what we did for them in those early days but there is no end to the good things they did for us. They were our teachers, our companions and our friends. The aspirants taught us the Dholuo language and from our close association with them we learned their culture and their customs. They would introduce us to the people and take us on safari to the villages around Kowak.”14 Dholuo (Luo) was the dialect of the people with whom the Maryknolls worked, and the sisters also learned Swahili, the everyday language of British East Africa. Once a month they operated mobile clinics that lasted three days, thereby making the isolated areas more accessible to biomedical health care. Accompanying Sister Margaret Rose to Kowak was a registered nurse, Sister Catharine Maureen Bowes, who ran the dispensary; and her services soon became more popular than the religious services. Sister Catharine Maureen received her bachelor of science in nursing in 1945 at Teachers’ College, Columbia University. She had extensive experience in public health nursing and took a four month’s postgraduate course in obstetrical nursing in June 1948 at the Margaret Hague Maternity Hospital, Jersey City, New Jersey.15 Upon her arrival in 1948, Sister Catherine Maureen faced many problems that affected maternal and infant populations. As Nancy Rose Hunt notes, “maternal and infant health care as a movement dedicated to saving the lives of mothers and babies was a global phenomenon by the interwar period.”16 Continuing into the mid-twentieth century, the Maryknoll Sisters focused much of their work in this area. Not only did they dispense medicines and provide health instruction but their dispensary also served as a training area for local people to do the same. The Kowak dispensary served a large area, with the nearest hospital being a Mennonite facility at Shirati, thirty miles to the northwest, which had been in existence since 1934.17 A government hospital was thirty-five miles southeast, but people had to cross a large bay on a ferry to get there and

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the ferry ran only once a day. A lorry conveniently passed the Kowak mission daily. Although transportation arrangements were important, it is significant that most patients came on stretchers accompanied by family members.18 As Steven Feierman notes, different options for healing existed, and it was the family that made the ultimate decision as to where to take the patient.19 Sister Catharine Maureen worked in an arena where illness, birth, and death were frequent occurrences. As a full-time nurse in the dispensary, she diagnosed disease, prescribed medications, made home calls, cared for the dying, and delivered babies (but only in emergencies because of a lack of facilities). The sisters housed women who had to stay overnight in an abandoned hut that they had fixed up on convent property. The statistics of the Kowak dispensary are revealing about its operation. Table 3.1 shows that in the early years, births averaged two per month but increased between 1951 and 1956. Dispensary numbers rose as well: sisters and their coworkers treated 1,167 patients in May 1951 and 2,653 four years later. After the rains stopped in early May, more patients arrived because the rivers could be crossed. Home visits were important from the beginning and continued throughout the period. Table 3.1 also reveals that mothers coming to the prenatal clinics increased over time, from 74 in 1953 to 128 in 1955.20 Note the reporting of not only the medical statistics but also religious outcomes, including the number of baptisms and candidates (aspirants) to the new African religious novitiate (the training period), which had also increased by 1956. Congregations had to keep statistics of successes with baptisms for the community’s motherhouse. In terms of productivity, however, the number of baptisms was not large. Working without government assistance, the sisters struggled to keep the dispensary afloat financially. They charged a small fee, approximately one to two American cents per visit, along with payment for any drugs. Nuns were able to purchase drugs such as mepacrine, aspirin, and medicine for worms at a discount from Kenya and received other supplies as donations from home, which allowed them to provide care at less than cost and for free if needed. Sometimes patients used the barter system and paid in chickens or fish. In 1950, the sisters and their assistants were

TABLE 3.1

Monthly Statistics, Kowak Dispensary, 1951–1956

Patients

May

Dec.

May

Dec.

May

Dec.

June

Dec.

June

Dec.

June

Dec.

1951

1951

1952

1952

1953

1953

1954

1954

1955

1955

1956

1956

1,167

1,131

1,827

2,001

1,569

1,718

2,602

1,408

2,189

1,538

2,653

1,627

3

1

2

4

4

9

12

10

8

17

6

14

19

8

18

16

14

190

126

245

128

18

14

17

16

22

1

1

1

3

25

Deliveries Home visits

2 26

16

8

Mothers at prenatal clinic Aspirants of native novitiate Baptisms

74 11

13

21

19

12

4

2

3

13

Source: Archives of the Maryknoll Sisters, Ossining, NY.

22

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working with a sphygmomanometer, stethoscope, and microscope donated by Americans at home. The Maryknoll Fathers purchased stoves for sterilizing, hot water bottles, blankets, syringes, and needles. There was only one examination table and a bed for emergency deliveries.21 In addition to limited equipment, the sisters faced other obstacles. The government’s national goal was to have one physician for every 1,000 people, but that goal was not met at Kowak.22 The Maryknolls did not have a sister doctor until 1957. In addition, although they studied the local language, the nuns were not prepared for the many Bantu patients who spoke other languages, and indigenous sisters translated, explained customs to the American sisters, and taught health to the patients in their native languages.23 Ranger notes that in Tanzania before 1945, biomedical treatment was mainly a failure, with the exception of the skin infection known as yaws. Before antibiotics, yaws was treated with potassium iodide and Norvarsan (novoaresenobenzol) injections. The most effective cure, however, was penicillin.24 When the Kowak dispensary officially opened in 1949, the sisters had no x-ray machine or any equipment to perform elaborate blood and urine chemistries. By the 1950s, however, Sister Catharine Maureen’s work reflected the revolutionary period that had begun in the late 1940s with the discovery and dissemination of sulfa drugs and antibiotics, which increased her ability to actually cure patients. She dispensed penicillin injections for infections and sulfa drugs for leprosy; cleaned, dressed, and stitched wounds; stanched blood flow from deep gashes; gave medicines for fever; and diagnosed diseases such as amoebic dysentery.25 These duties demonstrated the blurred boundaries between nursing and medicine as practiced in rural and bush areas. Sister Catharine Maureen’s work demanded not only autonomy but also specialized medical and nursing knowledge. Because there was no physician at Kowak, the government denied a grant application for assistance in 1950.26 The sisters had to make do with what they had, and the dispensary clearly had its limitations. Often families arrived with sick babies, and Sister Catharine Maureen could do nothing to prevent death. Sometimes patients arrived too late for effective therapy to be administered, and on other occasions sisters had to guess about what could best help. To get a glimpse of the nature of contact

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among Catholic sisters and African indigenous healers, a Maryknoll diary entry in 1949 described an event in which Sister Catharine Maureen delivered a premature baby who did not thrive. She tried all she knew to help the baby breathe and eventually gave up and baptized the infant. Yet, in the same room she allowed an African woman, a “pagan,” to stay, even though this was outside Sister Catharine Maureen’s cultural milieu. The diarist described the woman as beating “some sort of a cooking pot which she held over the baby’s head, and chant[ed] a pagan song to ward off the evil spirits.” Soon the baby started breathing.27 This multicultural approach to treatment was not common in the sisters’ dispensary in the 1940s. Indeed, nuns held tightly to their own religious beliefs and medical practices. In this case, the sister attributed the baby’s survival to the baptism rather than the chant. Yet even in a mission hospital, one might witness pluralistic healing—biomedical, spiritual, and indigenous. Catholic sisters’ actions at times clashed with what local African patients wanted. Sometimes the nuns baptized babies without parents’ permission if they thought death was imminent, while on other occasions they asked permission and followed up if the mother or father seemed interested in Catholicism.28 In the process, the sisters frequently denigrated the practice of witchcraft in their diaries and questioned the purpose and value of other customs. Yet the nuns did not limit their care only to those receptive to Catholicism. As an example, a local man made daily visits in 1949 and brought groups of sick people to be treated by Sister Catharine Maureen, although the sisters never succeeded in converting him.29 Like all Catholics in health care, Maryknoll sisters and priests believed that they could not heal by biomedical means alone. In the 1940s and 1950s, these American sisters adhered to a Catholic ethos that relied on sacraments, devotions, and prayers to the Virgin Mary as a means of access to the divine. Catholic theology held that grace, which the sacraments conferred, could save the soul of the dying, and to die in a state of grace required that a person have opportunities to receive the sacraments and be baptized. While only priests could administer the sacraments, nuns could pray, perform rituals, and baptize. Catholic teachings also emphasized miracles that resulted from intervention by Jesus, Mary, and different saints.30 As an example, in December 1951 an unconscious

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woman arrived at Kowak on a litter carried by a group of men. To the sisters’ relief, she had a “miraculous” cure the next day, as “the sisters did not know what caused her period of unconsciousness and subsequent illness.”31 But even with the aid of miracles, the nuns knew they could not cure everything. In 1952, when one woman needed to be transported to the Shirati facility, the sisters prepared to take her but the river was too high for the car to cross. The woman asked for the sacraments and the priest anointed her. The sisters decided to take her to the hospital anyway, and after reciting prayers to the Virgin Mary, they crossed a flooded river in their car. “With much lighter hearts,” they safely made it to the other side and to the hospital.32 “Hodi,” a Swahili greeting meaning to open a door, was a common call that the Maryknolls heard from patients’ family members as they came to the dispensary. It was not unusual for people to come in the middle of the night, such as a pregnant woman who arrived in December 1951 with what the nuns suspected was an ectopic pregnancy. The rivers had flooded and made transportation impossible, and one of the sisters worked all the next day before she could finally get the government ambulance to take the woman to the hospital.33 Sister Catharine Maureen also worked in conjunction with families when diagnosing leprosy. She dispensed a sulfonamide, Diasone, but the diarist wrote that the patients often diagnosed themselves and recognized leprosy lesions “better than a doctor or nurse.”34 Infrequently, the sister nurse had the help of physicians.35 In emergencies, Shirati Hospital provided a physician and surgeon. Most of the time, however, the sister nurse had to assess the patients’ condition and use her own judgment as to whether or not to refer to the hospital. When she recognized severe cases of malaria with complications or if she detected shock from bleeding, she called the government ambulance for transport to the hospital. One disease the sisters did not diagnose alone was tuberculosis. While many of the diseases the sisters treated were endemic to Africa, tuberculosis had spread after colonization because of wars, industrialization, and overcrowded conditions. Its diagnosis required a chest x-ray, and the sister nurse had to rely on clinical symptoms such as fatigue and family history before she referred the person to the Shirati hospital. Another physician, a Musoma medical officer, did monthly

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inspections of the Kowak dispensary. After 1953, Father Edward Baskerville, a Maryknoll priest, was also a physician at Kowak, and like the sisters his work combined religious commitment and medical care. One day he was called to help a woman who had been bitten by a snake, and he took a syringe and snake serum “and went off, hoping to attend the woman’s physical and spiritual ills.” It was the women missionaries, however, who primarily worked in health care while priests carried out pastoral assignments.36 In 1954, local Tanganyikans reported to a visiting United Nations group that they wanted “hospitals and maternity and child welfare clinics,” and they wanted the missions to build them.37 This further validated the Maryknolls’ work, and after the original dispensary burned, they built a new facility and expanded it to include an obstetrics ward. They still had no government funding at the time. The first Maryknoll sister doctor, Marian Jan Puszcz, an obstetrician and gynecologist, arrived in 1957; thus resources for doing Caesarean sections became available. Hunt argues that, in the Congo, women “unsolicited, actively sought out this kind of biomedical care during emergencies.”38 The same situation occurred at the Kowak facility. As women and men saw that a physician could save the lives of women with complications of childbirth, they came more frequently. For the sisters’ part, they viewed the dispensary as the “best way to win the confidence of the people and . . . a stepping stone to a more basic program of public health education.”39 This led them to hold prenatal and well-baby clinics where they disseminated information about maternal care and childhood diseases.40 Sisters tried to understand the culture by taking classes on local history and Swahili, but their Western values came through in their teachings about issues such as housekeeping and hygiene. Much of the instruction, such as not sharing houses with livestock, was justified, but their diaries also make clear that they used their classes as an opportunity for conversion and for bringing wayward Catholics back to the fold.41 This is not to say that they did not have a concern to save lives, but clearly that was not their only mission. On other occasions, tensions occurred among families and nuns when sisters’ actions resonated with the Catholic Church’s strong emphasis on women’s roles of motherhood. For example, the sisters’ sympathy for

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young mothers came through when they tried to protect them from being taken back to their villages too soon after birth, because they knew that the women would be put to work in the fields. One woman had given birth to twins; one died, and the other weighed only three pounds. The Maryknoll diarist wrote that the mother “never took her eyes off the crib. . . . She wanted so much for this baby to live.” She stayed at the mission a month, and while different family members came daily to take her home, the nuns resisted and finally convinced the chief that the woman needed to stay.42

Tanzanian Assistants Local community workers served as the sisters’ important links to the patients. When the Maryknolls arrived in 1948, there were several medical auxiliary positions available to Africans, including assistant medical officer or hospital assistant. The nuns themselves trained many of their assistants to carry the biomedical message to their local communities, which became a major tactic to replace “sorcery.” With the help of a young African candidate to the local novitiate whom Sister Catharine Maureen trained, they went to local villages to treat the sick at families’ requests. Sisters also had assistants in their dispensary. A typical day in 1961 involved opening at nine A.M. with a local man being the first to receive the patients. Separating new from returning ones, he assigned them cards stating the routine drug and dose as ordered by the sister nurse or doctor. He then sent all returning patients with malaria or helminthic infections to two Luo men who had been trained by the sisters in giving injections. These men treated nearly half of the outpatients. All new patients had to bring stool and urine specimens that would be examined by another assistant who recorded the result on a card and registered the results in the sisters’ ledger. The assistants did not act independently from the sister physician or nurse, who saw all new patients and diagnosed them. More than half had malaria or bilharzia, determined by the patient’s history, physical examination, and urine and stool examinations. The sister doctor checked the nurse’s findings and then discussed the diagnosis and treatment with the new patients.43 Anne Digby and Helen Sweet, in their work on colonial South Africa, have described the assistant to the mission

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nurses and doctors as a “cultural broker.” He or she could explain Western ideas about medicine to local populations by using terms familiar to their own understandings.44 In a similar way, the Maryknoll’s assistants occupied key positions in Catholic mission medicine based on common language and other specific skills that they could do as well as or better than the sisters. Implementation of clinics depended greatly on their cooperation. Digby and Sweet’s work on South Africa and Markuu Hokkanen and Charles Good’s studies of Malawi have shown that, in Protestant missions during the colonial period, some Africans could expand their intellectual pursuits and personal status by obtaining training in nursing, laboratory analysis, and other clinical training.45 A similar process occurred in Catholic hospitals and in smaller clinics and dispensaries during decolonization and independence. In addition to helping with dispensary work, Tanzanians knew the local people, their problems, and where they lived, which in turn facilitated the sisters’ work. Successful collaboration on the long trips to rural villages made it possible to maintain the sisters’ practice.

Public Health in the Context of National Goals Through pressure from the Tanganyika African National Union (TANU) and under the leadership of Julius Nyerere, the country became an independent republic in 1961 and united with Zanzibar to become Tanzania in 1964.46 After election as the country’s first prime minister, Nyerere’s immediate goal was to undo British colonial policies. In the process, he nationalized the schools and ordered that Swahili be the official language. The government also shifted its focus toward maternal and child care, and the Kowak dispensary, with a physician in residence, finally received government funding for staff. By then, there were 737 dispensaries and health centers in the country, 204 antenatal clinics, and 195 child health clinics.47 Government funding helped the sisters to comply with the country’s emphasis on preventive clinics. It provided salaries to nurses for dispensary work, thereby freeing up the sister doctors and nurses to visit outlying villages in safari clinics. In 1961, the Kowak facility was a small hospital of sixteen beds with a five-bed maternity unit, although it was still not equipped with x-ray

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machines; blood transfusions were not given, and only a few patients received intravenous fluids. The sisters and their assistants saw 70 to 100 patients daily, and they treated many endemic diseases, the most frequent being malaria (354 cases), upper respiratory infections (213 cases), ascariasis, a roundworm infection (103 cases), and the tropical parasitic disease vesicle schistosomiasia (89 cases). They also treated burns, vitamin-deficiency diseases, snake bites, and more than 70 cases of leprosy. In July 1961, they cared for 1,883 Africans, 4 Asians, and 6 Europeans in the outpatient services.48 Health education had long been a role for American nurses, and the Maryknoll Sister nurses were no different. Beginning in the early twentieth century, American nursing leaders and social reformers had championed nurses going into homes for health education. As the public health movement expanded, voluntary agencies carried out preventive measures for mothers, children, and those with infections.49 This translated to Tanzania in the 1960s as prenatal and well-baby clinics expanded under President Nyerere. In 1961, a Maryknoll sister and her assistants held well-baby clinics each week where they weighed and examined infants. One mother had birthed seven infants but only one was living, and she brought the child to the clinic each week. Three different times the sister nurse found the baby to be anemic, so the mother and child stayed at the mission for several days until the baby regained its strength. The sister nurse continued to hold prenatal classes where she taught personal hygiene and cleanliness and the need to boil water and milk. Other teaching topics included covering the baby in cold and inclement weather, using a spoon to feed small infants, instruction that powered milk was available for supplemental feedings and how to prepare it, and the basics of labor and delivery. The nurse also spoke of the advantages of delivering in the hospital rather than at home, particularly for emergency cases such as when women were in labor for days at a time.50 African assistants were helpful in eliciting the confidence of their local communities in these clinic activities. In 1964 the sisters asserted, “If we as white people teach the village women, our ideas are looked upon as foreign and the ideas for the white man. If we can use our African villagenurse to propose and to teach the basic health needs, then they are better received and more surely put into practice.”51 At the same time, without a

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school of nursing to staff their facilities, the sisters were short-staffed and needed the extra help. And one important way to save money was to hire locally recruited staff in subordinate positions. Significantly the Tanzanian government also followed the strategy of hiring local maternity aids who were older married women. As one government report noted, “This would contribute to their influence in the local community and their understanding of the problems of motherhood.” In that way, they would be more able to gain the confidence of the mothers for education purposes.52 In the 1960s, Sister Nurse Margaret O’Brien went on safari clinics from Monday through Friday and took a nurse aide and several young girls with her. They covered a thirty-to-seventy-mile area. The diarist wrote that they “have things worked out so efficiently that in isolated villages they can take care of 600 women and children in a day.” In addition, “a Netherlandstrained nurse midwife, a native, holds forth in the Dispensary and keeps the 26 beds busy, using an invaluable local dispensary-aid, trained by the Sisters and now famous. Local people also take care of supplies, Lab work, and the general routine.”53 These assistants were able to negotiate between their own social networks and the sisters’ dispensary, and nuns held them in high regard. By 1964, the Maryknolls had seven sisters at the mission and four fully trained African nurses who had been educated in the biomedical model in other Catholic schools of nursing in the country.54 Prevention activities continued to be important national goals. According to a 1964 government report, nearly half of the country’s population consisted of children under the age of fifteen, and few people lived to an old age. High infant mortality rates continued into early childhood and resulted in the deaths of 30 to 50 percent of the children. No government data were available to explain the high mortality rate, but it was generally understood to be from malaria, malnutrition, pneumonia, and gastrointestinal disorders.55 Since the 1950s, the WHO had been active in a global malaria eradication program, but by the mid-1960s the program was obviously failing. In 1967, the WHO launched an intensive smallpox vaccination program, which eventually proved very successful, and the sisters participated by giving smallpox vaccinations in their clinics.56 As they made their safaris to hold clinics in outlying areas, the nuns often described harrowing adventures into the bush. In the late 1960s, a

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sister was working out of another Maryknoll clinic and went on a safari trip thirty-five miles away from the mission station. She took Regina, a Tanzanian nurse midwife, and several grade-seven middle-school girls from the local Catholic school. They had to drive through muddy roads and two flooded rivers, but they were determined to get to the 450 women who would be waiting for them. They finally arrived after wading through a river and carrying supplies on their heads and in their arms. As they set up the clinic under a tree, one young girl made out cards for each woman and set up a filing system, and two filled women’s containers with powdered milk and cod-liver oil that had been donated by the Catholic Relief Services (CRS), the international relief agency of the Catholic Church, and the United Nations Children’s Fund (UNICEF).57 Another girl gave injections and vaccinations, one gave health classes on sanitation and nutrition, and the sister and nurse midwife examined the prenatal and postnatal patients. On their way back to the mission, they battled swollen rivers, mosquitoes, and hyena howls. The Land Rover stalled and they had to get out and push, but after they made it across the river in the dark, the gas pedal fell off. Tanzanians in a passing truck took Regina and two girls to get help, and the others were stuck for three more hours until another group of Tanzanians arrived and wired the gas pedal back together. The repair did not stick and the pedal soon broke again, which led to more waiting. The Maryknoll Fathers eventually came along and, enthusing that “We haven’t had so much fun in years,” they towed the women twenty-five miles back to the mission.58 Indeed, it was not unusual for the nuns to delight in the retelling of their perilous adventures.

Cultural Conflict in Mission Medicine In January 1965, a dramatic demonstration of African agency reveals the ultimate power that Africans themselves held over the mission. It also shows how sisters’ and Tanzanians’ beliefs about health care costs differed. The sister superior at Kowak received a letter from the area commissioner of North Mara that described several complaints from the public about the way the sisters treated their patients. Specifically, relatives charged that the nuns had denied treatment to pregnant mothers until they paid a fee. The area commissioner noted, “I personally received

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complaint that on 11/1/65 one woman of Bunjari who was expecting a baby was brought to your hospital at 3 P.M. for delivery but you refused to attend her till the payment of the fees.” He visited the hospital himself on December 1, 1965, and claimed at the time that the sisters had indeed refused to attend an expectant mother. “I am taking this matter into deep consideration and concern that I would like you to give me your full explanation about these complaints and why you do refuse to attend and treat the serious patients brought to your hospital till receipt of the requisite fees.”59 He sent copies of the letter to the regional commissioner and the regional medical officer. This account by Tanzanians can be contrasted with Sister Marian Jan’s reply informing the commissioner about the medical aspect of the cases. She assessed the care from her role as a scientific medical practitioner: [One] patient was brought in during the early hours of the morning with a history of having delivered twins at home the day previously; the afterbirth had not yet been delivered. The twins were premature and small but in good condition. The patient had a fever and markedly infected uterus. She was not bleeding at the time of admission. It was decided to give her antibiotics to control the infection. She was exhausted and very tired from the long drawn session of delivering in her village and was likewise given medicine to rest.60

The sister explained to the husband that the “afterbirth could be removed only after she was adequately prepared” for surgery. The operation occurred about 10 A.M., and the patient was discharged “in good condition.” The sister also noted that another woman had a history of a previous stillbirth. Then: On admission the baby was found to have already died in utero— and both parents as well as the family were informed of this matter. She had a fever—was frightened beyond measure—and in so much pain that nothing more than an abdominal examination could be done at that moment. She was immediately given antibiotics and medicine to bring down the temperature, also medicine for her pain.61

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The sisters treated the fever and dehydration before delivery. The woman received fluids during the night and pain medicine and antibiotics. At 9 A.M.,

one of her relatives came and asked why she had not yet delivered

and was told that “she was not yet ready but would deliver shortly.” An hour later, she was given anesthesia and, with a “high-forceps application” delivered “a macerated stillbirth infant.” The woman soon recovered. Sister Marian Jan reiterated their practice of preparing patients adequately before any surgery was performed. In cases of hemorrhage or the possibility of “saving a living child,” they did not wait. All other patients were prepared with fluids, blood transfusions, antibiotics, and analgesics. They felt fully justified in their practice because of the “very low mortality rates we have had in our maternity unit over the years—in spite of the fact that some are brought to us many hours (or days) after they have delivered at home or at another hospital for complications sustained.”62 She sent copies of her response to the regional commissioner, the regional medical officer, and Bishop John Rudin of Musoma. Sister Marian Jan also wrote to her superior. She thought the complaints reflected “the spirit of the present moment.” If the nuns did not immediately operate, “people follow us around all over the compound—insisting it get done immediately and sometimes they get quite nasty about it” and accuse the sisters of neglect. She was also concerned about government interference with her practice of medicine. As the government became more involved in mission work through financial subsidies, she realized she did not have full medical control over her patients: “If I am to be told when and how to take care of patients here at Kowak then . . . it is going to take a great deal more consideration to approach the matter of working under the government auspices, even part-time.” She noted that “the patients will probably look upon the money aspect as the most important, but as far as we are concerned it was not significant at all.”63 Sister Marian Jan also informed her superior of an exchange among the bishop, the regional commissioner, the medical officer, and herself during a visit. “As a private hospital,” the sister and bishop told their audience, “the sisters were justified in charging patients.” Furthermore, Bishop Rudin pointed out that patients could go to government hospitals if they wanted free care. Significantly, the bishop told the commissioners: “If the government would like us to become associated with them even more closely—then, there will be even less of a problem because the

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government will supply all drugs, care for all expenses and then we shall not have to be concerned with any fees at all.”64 Bishop Rudin also wrote the area commissioner, denying vehemently that the sisters refused patients until payment was received. He, too, defended the sisters’ fee collections as a necessity for a private hospital, that the money was used to buy medicines and equipment, and that the fees were comparable to other private hospitals. Without charging, they could not make ends meet. He then requested that any serious charges against Kowak be referred to “competent government authorities who know medicine.” He closed by assuring the commissioner that the Catholic Church wanted to cooperate with the nation’s goals for the country and that the Church’s record in health care over the past years had validated that aim.65 It is clear that the family members and Sister Marian Jan assessed care to the patients on very different bases. Conflict involved differences in explanatory models of disease treatment, but payment issues also were paramount in the Tanzanians’ minds. Steven Feierman’s explanation of medical uncertainties among one particular group from Tanzania can be useful here. He notes how their understandings of treatment efficacy were very different from scientific explanations such as those Sister Marian Jan provided. In Tanzania relatives and neighbors provided nursing care for their sick family members and friends. They were the ones who brought their ill relatives to the hospital, and they also paid for the costs of care. Hospital payment systems could be confusing for those who expected to pay only if the patient was cured or if the outcome was positive, as was often the practice with indigenous healers. Yet hospitals demanded money whether or not the patient improved, which could cause great bitterness if the outcomes were not good.66 As much as sisters tried to comprehend the local culture, their own scientific understandings of childbirth and its complications conflicted with local understandings, especially regarding the timing of therapeutic effectiveness. These misunderstandings were not bridged, and the Tanzanian government requested that the bishop transfer Sister Marian Jan immediately.67 Bishop Rudin tried to meet with the regional commissioner, but due to the latter’s absence he had to speak to the regional secretary. The bishop informed him that Kowak Maternity Hospital would have to close

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if they did not have a physician, and Sister Marian Jan’s monthly safari trips would necessarily cease. Other Tanzanians sided with the sisters. On March 10, 1965, the chairman of TANU for the North Mara region, who had heard the hospital was closing, approached Sister Marian Jan. He and other Tanzanians claimed to have had no knowledge of the plans and they protested strongly. Two other people from the Luo Imbo district also visited the sister and asked her to “slow down on your packing until Edward [the TANU leader] sees everybody he has to.” They had written letters to the regional commissioner, area commissioner, and to government leaders in Dar es Salaam.68 The Tanzanian Episcopal Conference of national bishops also got involved and conferred with the minister of health. On March 20, the minister wrote the bishop to request that Sister Marian Jan not be removed as yet. He suggested she instead serve as a physician in the government-run Musoma Hospital under the grant-in-aid program. She could stay at the sisters’ convent and the government would provide transportation for her.69 This plan did not materialize, however, and Sister Marian Jan was transferred. As the diarist noted in late 1965, “We were saddened early in the year by the events which ended in the departure of the Sister-Doctor from Kowak Catholic Hospital, and the subsequent drop in patient attendance for a long period.” Because of the lapse in surgeries, the sisters no longer needed many of the staff, who had to be transferred elsewhere. The nuns compensated by increasing their safari trips to people who could not get to the hospital for examinations, and they continued to do both preventive and curative work.70 Maryknoll Sister Margaret O’Brien, who had worked as a nurse at Kowak in its early years, returned in 1970 and remained there for eight years as the only Maryknoll sister.71 It was at that time that the Tanzanian Immaculate Heart Sisters, who had become an official congregation in 1955 after Maryknoll mentorship, became active in Kowak’s medical and nursing care.72 The Maryknoll sisters’ health programs had created the means for these Tanzanian women to translate biomedicine to others, but, by comparison, the women in this local congregation also maintained their own worldviews that were more similar to those of the people. For this reason, they probably did not have the cultural conflicts the Maryknoll Sisters experienced.

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The Maryknolls and Politics Despite the cultural clashes noted above, the Maryknoll Sisters increasingly enhanced their knowledge of and respect for Tanzanian culture. Whereas Vatican II influenced them tremendously, so did political changes in Tanzania and new theologies of liberation. The idea that missioners could be influenced by Africans themselves can be seen in the Maryknoll Sisters’ work with Julius Nyerere. When Tanzania gained its independence in 1961, the Catholic Church had made considerable inroads into the country. The Church had 1.5 million members, 1,163 missionary and diocesan priests, 1,452 sisters, and 405 brothers.73 By 1962, Nyerere had begun his “African socialism” plan that focused on self-reliance and development that involved rural communities’ participation. Catholic priests had educated Nyerere and he discussed many of his ideas with them. As well, Catholic social thought after Vatican II influenced him and he remained a practicing Catholic all his life. Nyerere was quick to assert that his socialism was different from communism in that it included religion; but religion was to be practiced in a secular domain and was not be a part of the state. He encouraged Catholics to cooperate with his ideals of “Ujamaa,” his socialistic economic development plan that he had outlined at the Arusha Declaration of 1967. This involved the nationalization of industrial and commercial systems, and it expanded in the 1970s to include setting up traditional family units that lived and worked in communal villages rooted in African communities of the past.74 On June 19, 1970, President Nyerere visited the Maryknoll Sisters in Tanzania, and he soon made plans to visit their motherhouse in New York. Sister Miriam Rachel Kunkler, the Maryknoll director of planning, had invited him to speak to the sisters’ General Assembly there, where fortyone sister delegates who represented sixteen different countries would attend. The theme for the assembly was “Maryknoll Sisters’ Participation in the Development of Peoples.” The sisters had been discussing the problem that nearly every one of the countries where we work is experiencing a strong thrust for economic, cultural, social, political, psychological and even ecclesiastical independence from foreign domination in its various forms. Since the poorer nations are now becoming

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poorer while the rich nations are becoming even richer, and since most of us come from the strongest and wealthiest nation, one which exercises great economic and even political control in the Third World countries, we must be well aware of all the factors involved in this issue and frankly face the consequences which may affect our presence in these areas of the world.75

As well, “Maryknoll has more than fifty years’ experience of missionary work abroad and also has a real responsibility and obligation to educate the Church and Government of America toward their responsibilities to the Third World.”76 Development rhetoric had begun after World War II when countries from the Global North expanded their aid to less developed countries not only to improve health but also to fight against communism. During the 1960s and 1970s, a renewed focus on development emphasized long-term socioeconomic growth rather than short-term technological solutions.77 It also is important to note that this was a time when criticisms were increasing toward missionaries as racist colonial oppressors. Development rhetoric became more noticeable in mission writings all over the world. Furthermore, with increasing secularization over the twentieth century and a growing global consciousness, secular international agencies embraced development discourse, with some transforming into faithbased NGOs.78 And after Pope Paul VI issued the encyclical Populorum Progressio (“On the Development of Peoples”) in 1967, which called for improved living standards for all, some Catholics suggested that development had become the “new name for mission.”79 In the United States, the Catholic Campaign for Human Development, an antipoverty and social justice program, began in 1969, sponsored by the U.S Conference of Catholic Bishops; and it particularly supported grassroots activism. Development terminology became the face of change in mission for both Protestants and Catholics.80 On October 16, 1970, when President Nyerere was in the United States to address the United Nations, he accepted an invitation from the Maryknoll Sisters and spoke at the motherhouse in Ossining, New York. In his address, “The Church and Society,” he stressed the importance of the sisters’ development and educational efforts in Tanzania. Yet he also

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criticized the Church: too often it had not addressed the social ills of society and had resigned itself to unjust social, political, and economic systems. Discussing poverty in Tanzania and the growing disparities between the rich and poor, he called on the sisters to move out of their isolated mission stations to work more closely with their African communities, perhaps living together and working with them in the fields.81 Sister Miriam Rachel wrote President Nyerere a week after the speech: “It was a great pleasure and a privilege for us to have such a visit with you and has renewed our commitment to make even greater efforts to help promote the policies you clearly put forth for Tanzania and Africa.”82 His speech came at an important time when the Maryknolls were redefining their identity and mission in light of Vatican II and were planning their policies for the next four years. The sisters had been discussing their future course for mission, with significant sessions occurring in 1964 and 1968. Then in 1970, sister delegates from all over the world attended their general chapter meeting, and they affirmed the grassroots approach to mission that was occurring in Latin America. Rather than converting “pagans” and establishing indigenous churches, the sisters voted to become more unified with people of different cultures wherever they worked. They replaced their religious habits with civilian clothes and committed themselves to more closely embrace the preferential option for the poor.83 Timothy A. Byrnes provides a compelling analysis of the sisters’ encounter with politics, noting that they believed that “it was the role of their Catholic Church to comfort the afflicted. And if that meant putting their Church and themselves in conflict with land owners, military leaders, local political elites, and US foreign policy, then so be it.”84 By the early 1970s, the Maryknollers were playing central roles in liberation theology. At that time, a more radical model of liberation had begun to take hold among some religious leaders, especially in Latin America.85 In calling for a special option for the poor, liberation theology advocated for “social betterment” rather than “individual conversion,” and for the eradication of hunger, injustice, and persecution.86 In El Salvador, where political oppression was stifling, Maryknoll Sisters Maura Clark and Ita Ford along with other priests and missioners were murdered because the state deemed the Church a threat for supporting the poor. Another sister, Carla Piette, also became a martyr when her Jeep

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overturned in a flooded river while returning a freed government prisoner to his home. Maryknoll sisters’ involvement in liberation theology led conservative columnist William F. Buckley Jr., to accuse them of “Christian Marxism.” Maryknoll priest Father William Boteler denied that liberation and Marxism were the same. He and others invited Buckley and Michael Novak to live with them in a Lima slum or African village, but neither Buckley nor Novak did so. “It probably would play havoc with their thought patterns,” said Father Boteler.87 Yet, with the exception of South Africa and the expansion of black liberation theology in that country, liberation theology in its more radical Latin American form did not grow in Africa. In Latin America, Catholic ecclesiastical leaders had been part of the small percentage of the wealthy population, and many had supported the elite and the military. They stood out in comparison to the deeply impoverished masses, many of whom were Catholic. Liberation theology critiqued the Catholic Church’s role in society and was an attempt by priests and sisters to unite the Church with the plight of the poor. In addition, the historical settings were different. Catholicism had been established in Latin America for over four hundred years. By comparison, in Africa the Church consisted of relatively recent converts, and there were few internal ecclesiastical conflicts. Indeed, there was little sense of class struggle inside the Church, “of positing a ‘church from below’ in opposition to the hierarchy,” as one African Catholic bishop noted.88 In the 1980s, liberation theology became a threat to leaders in Rome, who eventually imposed a year’s “silence” on some of its leaders. Yet in the 1970s it was still widely discussed among the Maryknoll priests and sisters and Africans themselves. In Tanzania, both Protestant and Catholic churches became critical to the support for change.89 The Maryknoll Sisters read widely on oppression in Tanzanian society, and they actively became involved in Ujamaa, Nyerere’s development scheme. After President Nyerere called for the churches to be where the people were, many Maryknolls did, in fact, move out of their mission stations. Although the Ujamaa policy eventually proved controversial among many Tanzanians, one sister wrote, “It is probably safe to say that almost any Maryknoll Sister who was in Tanzania during the 1970s was involved in and supported” Ujamaa.90 One sister nurse carried out health surveys in sixteen villages

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and trained village local health leaders in a project associated with the Medical Missionaries of Mary.91 Some nuns chose to live and work in the Ujamaa villages, tending fields and gardens, carrying their own water from the communal well, and carting rocks for construction. The various churches had always favored people living in close proximity to each other because it was easier to organize Church activities, but this was a new style of mission. As the sisters went to the fields together with local villagers, they learned from one another and redefined what mission meant.92 One Maryknoll nun, Sister Jean Pruitt, worked with the Catholic Relief Service and was amazed at the immense material assistance this organization could provide. As a transnational actor, it channelled funds from the United States and solicited assistance from the Europeans. Sister Jean noted that the CRS was truly “redistribute[ing] the wealth of nations.” As its representative, she visited regional medical officers of the country as well as the Ministry of Health and persuaded them to help pay for a preschool nutrition program for children with kwashiorkor.93 This protein deficiency disease resulted in anemia, swelling of hands and feet, and large protruding abdomens, and it proved especially lethal to children.94 Revealing how resoundingly the sisters’ focus had changed, Sister Jean, too, lived in different Ujamaa villages to help them implement the program. Other Maryknoll Sisters became involved in international voluntary agencies and catalysed their employees to work with vulnerable groups.95

“Agents of Change” The Maryknoll Sisters exchanged ideas with other members of their congregation through their monthly newsletter, Regional Rustlings. In one 1971 publication, for example, Sister Jane Vella suggested that the sisters read South African teacher and writer Es’kia Mphahlele’s Down Second Avenue because it resonated with their own changing scope of mission. She quoted Mphahlele: “I think now that the white man has no right to tell me how to order my life as a social being, or order it for me. He may teach me how to make a shirt or to read and write, but my forebears and I could teach him a thing or two if only he would listen and allow himself time to feel.”96 Two months later the newsletter had a large section on socioeconomic development, with the writer noting that it should be “an integral

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part” of mission. Another Maryknoll Sister wrote that development had been less important to the Church in the past because of the “great emphasis on individual salvation.” Now the Church should be “part of the revolutionary forces—acting as agents of change” and “participate in the struggle for the creation of national ideologies and elaboration of development plans.” She recognized that the sisters could only make a small contribution but should unite with Protestants, donors, and receivers of aid. This meant a more critical examination of their educational systems, both secular and religious, and a greater concern for justice and peace. Most important, “there ought to be a constant flow of ideas in a two way stream.”97 Sisters also began reading from leading theologians, even though theology was traditionally a subject restricted to the male clergy.98 In another Maryknoll newsletter, the editor quoted from Paolo Friere’s Pedagogy of the Oppressed.99 Friere had drawn upon the ideas of liberation theology when he wrote about the importance of open dialogue and working directly with the poor. The newsletter editor also recommended that all sisters read Brazilian archbishop Dom Helder Camara’s book Church and Colonialism.100 As a leader at Vatican II, the archbishop was a champion of the poor and a great supporter of liberation theology. The book was “a call to humanity . . . to take note of the tragic situation of the underdeveloped world.”101 The July 1971 newsletter quoted excerpts from an interview with Liberian-born Burgess Carr, an Episcopal minister who was secretary general of the All Africa Conference of Churches. Significantly, he asserted that foreign missions should not go home, but he reacted against the rather patronizing term of “development” when he asserted that “some kind of relationship must develop so that the churches in Africa help the churches in Europe and the U.S. and vice versa.” Indeed, Africa was not the only continent needing development.102 Maryknoll Sister Janice McLaughlin was one of the more radical sisters who worked in Rhodesia in 1977. She became secretary to the Justice and Peace Commission, a group established during Vatican II to work for social justice, poverty eradication, and a preferential option for the poor.103 Sister Janice documented cases of brutality by leaders of the white minority government, and she called for Prime Minister Ian Smith to step down. Consequently, she and three commission members were arrested

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and accused of being communists and supporters of terrorists. Although she denied the accusations, in the courtroom she admitted that she believed a revolution was needed to redress injustices and bring about more fair distribution of wealth. The African Catholic Church supported her, and after more than a week in jail she was released and deported. She took her message back home to the United States and to Europe, to insist on changes in foreign policy.104 The politicization of the Maryknoll Sisters was not unquestioningly supported at the motherhouse in New York, however, and many sisters did not approve any work associated with liberation theology. While the vast majority of Maryknoll Sisters in Africa did not call for revolution, they did continue to dialogue with other Africans. At an assembly in 1978, Anselm Odhiambo Anacleti, a professor, government representative, and former student of the Maryknolls, outlined the changes in Tanzanian society in the previous thirty years. Most important, he noted a decline in traditional social values that was due to political moves toward socialism as well as the spread of Christianity. Although he appreciated the social services the Catholic Church provided, he criticized schools. It was true that they had brought education to children, but as a consequence parental instruction on traditional Tanzanian values of “greeting systems, politeness, good language, and decency” eroded. Speaking of his own Catholic schooling, he believed it to be too rigid and that it stressed “the child’s relationship with God rather than his relationship with his neighbor.”105 In an interesting African perspective on missions, Anacleti pointed out that Africans took some of the mission messages and dismissed others. He praised the sisters for the spread of modern scientific knowledge and the liberation from magical practices. Nutrition was improved with greater protein intake. Indeed, “education and health services as well as community work in which you sisters have had a very large role have gone a long way in changing the traditions and customs that are hostile to the health development of the society.” Both government and missions had helped promote healthier habits. But he also noted that most Tanzanians who converted to Catholicism had lapsed without necessarily rejecting Christianity. In a more complicated picture of religious change than mission documents present, he noted that people in his village still visited witchdoctors, took second wives, and married their children to

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nonbelievers while at the same time attending Mass and receiving the sacraments. What Anacleti was suggesting was that religion rarely “changed their traditional faiths which joined them with the ancestors in pleading to God.”106 In the mid-1970s, 500 expatriate Catholic sisters from thirty-eight different religious congregations were in Tanzania, compared to 2,500 Tanzanian sisters in thirty congregations. Clearly the imbalance that favored foreign sisters was changing. While the Ujamaa villages did not refer to any specific religion or faith, Christians were increasingly taking over leadership positions in them. Still, some Catholic leaders feared the socialism of the policy, assuming it was communistic and atheistic.107 By contrast, the Maryknoll Sisters’ support of President Nyerere’s African socialism was important as they became more and more active in the national policy. When the president spoke to the sisters at their motherhouse in 1970 and cited the need for the Catholic Church to play a leading role in a social revolution, the Maryknoll Sisters listened. They were accustomed to living and working in communities and they embraced the project. By the mid-1980s, however, Maryknoll sisters were gone from Kowak.108 As occurred with religious congregations all over the world, many of them vacated the institutional structures of hospitals and schools and concentrated in other areas.

4 Catholic Medical Missions and Transnational Engagement in Nigeria

“

The Catholic Church has long been heavily involved in services of

education and health, and increasingly in development and relief . . . [owing] much of its standing to its international character, and to the human and financial resources it can therefore command. These resources mean that Catholic involvement in many areas can rival or even surpass the government’s. Certainly no other denomination can match it.”1 This statement by Paul Gifford serves as an opening to an analysis of how a Christian group such as the Catholic Church exerted tremendous influence in health care and, in the process, transformed itself to include relief work. This chapter expands the discussion of sisters’ political involvement by exploring the experiences of the Medical Missionaries of Mary (MMM), the Holy Rosary Sisters, and the Immaculate Heart of Mary, Mother of Christ (IHM) Sisters in southeastern Nigeria during a period of violence and upheaval. Working through Catholic religious networks that crossed borders, these sisters applied their professional expertise at the local level when other health care infrastructures all but collapsed.2 Their work was transformed during the Nigerian Civil War to include relief work. Indigenous integration of church institutions, including hospitals, also resulted.

Background: Nigerian Mission Nursing and Medicine Earliest contact between Europeans in what is now Nigeria occurred in the context of the seventeenth-century slave trade with the Americas. Then in 92

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1851, the port city of Calabar became the site of the British antislavery movement that provided a new impetus for missions. The following year, the British occupied Lagos and in 1861 annexed it as the first British colony in the area. To prevent French and German incursions, a British colonial administrator convinced local rulers to sign “treaties of protection”; by 1904, through various battles and subduing of local resistance, British forces had formed protectorates in both northern and southern Nigeria. In 1914 Britain joined the two protectorates, which forced many different ethnic groups to coexist as one political entity. Nigeria obtained independence in 1960.3 According to Ralph Schram, the first Protestant medical missionary came in 1730, followed by the Anglican Church Missionary Society, which spread its work in the mid-1800s. It was not until a half century later, in the 1890s, that Catholics established a hospital in Abeokuta in southwest Nigeria.4 Medical mission work in Nigeria was part of a wider revival of Catholic mission activity throughout the world in the late nineteenth century. Protestant missions dominated in the country before 1886, but thereafter Catholic influence was established when the French Spiritans, or Holy Ghost Fathers, arrived. Because British Protestants viewed the French fathers as political agents of France, a period of strong rivalry for both religious and political conquest began.5 Nigerian scholars have been especially critical of these early missions. To F. K. Ekechi, missionaries’ dispensing of medicines was not humanitarian work but instead a means to entice people to accept Catholicism. Some missionaries demanded that children be baptized so they did not die in sin, and these baptisms certainly made dents into Protestant mission activity.6 E. A. Ayandele describes a series of British military expeditions into Nigeria in the first years of the twentieth century that “began the halcyon days of Christian missions.”7 Indeed, it was in the early twentieth century that missionaries became more closely allied with Britain’s national interests, and they became key players in obtaining British protection for their efforts.8 Within this movement the Irish played a leading role. Whereas the French Holy Ghost Fathers had initially gone to Nigeria, Irish mission work in Nigeria expanded in 1905 when Irish-born Bishop Joseph Shanahan took over the leadership of the Holy Ghost mission. By 1920, the French

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had withdrawn completely as a result of the Vatican’s decision to give eastern Nigeria to the Irish. By then, the Holy See was apportioning mission territories according to political expediency, including the similarity of the missionaries’ nationality with colonial authority in specific mission areas.9 The Irish were more accustomed to working with the British than the French, and even though Ireland had a long problematic relationship with England, the Irish fathers adjusted.10 Father Shanahan’s priority was to convert more Catholics; to him schools were the best instrument of conversion for children who would then be trained as Catholic teachers and future leaders. He became a master at working with the colonial administration. Within sixty years, his mission accounted for over two million conversions in the eastern region.11 By contrast, the colonial government did not encourage Christian mission work in the Muslim region in the north. Furthermore, Islamic influence was negligible in the east. Protestant influence was greater in the west with the Yoruba, where Catholics had fewer commitments. And even though Protestants made up the majority of Christians in Nigeria, more than three-fourths of the Catholics in the country resided in the southeast. The Igbos (Ibos) were particularly influenced by Christianity due to the phenomenal growth of mission education in this region. Igboland soon became Ireland’s center for Catholic mission. One Catholic source stated, “It is among the Ibos that the real strength of the Catholic Church lies. The Ibos are often called ‘the Irish of West Africa.’”12 The British colonial administration built the first government hospital in Calabar in the southeast, and by the start of World War I, twenty-six medical facilities were in existence, including one leprosy asylum. It was not until the interwar years, however, that Christian missions expanded, especially Catholic facilities. Andrew G. Onokerhoraye notes that by 1930, there were seventy-one hospitals, twenty-three of which the missions owned. The Holy Rosary Sisters began hospital work in the 1930s, and both the MMM and the IHM Sisters were established in Nigeria in 1937. At this time, formal training of nurses and midwives began in many of these mission hospitals and in a few government facilities. In 1951, 157 hospitals were in existence in Nigeria, fifty-nine of which were mission establishments.13 As in other parts of the world, the Catholic health care contribution in Nigeria was the work of nuns, in this case both Irish and Nigerian sisters.

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Conversion remained the goal of mission facilities in the early years. In 1948, for example, the MMM helped produce a film, Visitation, on leprosy control in Ogoja province. The film shows how conversion was a high priority among the inhabitants of leper colonies.14 In 1949 a priest wrote about the importance of medical work for conversion, and he especially detailed the role of Nigerian nurses: “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.” In their attempts to reach more Nigerians, then, the missioners targeted Nigerian women to transmit mission ideas. Although the bishop emphasized that the patients who came to the hospitals and dispensaries were “quick to see that the Missionary has no other desire than to help them,” clearly the cleric’s priority was to save them spiritually.15 He viewed the Nigerians nurses themselves as most influential in working with others. Two hundred nurses were “co-missionaries.”16 Protestants and Catholics competed in the health care arena with little interaction between them, and a traditional health system complemented the modern one. All served the same population.17 During the periods of decolonization and independence, national development plans earmarked additional funds for health facilities in Nigeria. In light of the contribution of missions to health care, a 1949 report by Sir Sydney Phillipson, the British commissioner for regional administration in the Gold Coast, called for increased grants-in-aid to mission hospitals, and Catholic missions took full advantage.18 This came at a crucial time: they had resisted government support because they feared government control, but after 1945 missions were expanding and they needed the funding. A Holy Ghost priest collaborated with Phillipson by supplying statistical information about the Catholic missions.19 And the MMM soon became the beneficiaries of government grants. In 1952, they had been operating on a shoestring budget, and they were particularly strapped when staff nurses at one of their hospitals asked for higher salaries. To keep up with government salaries, which were much higher, the sisters granted the nurses a 50 percent increase.20 To help with this, in 1953 the MMM received grants for nurses’ salaries and for beds.21 This government support came when the regional Nigerian government also was seeking greater control over primary schools, where

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Catholics were particularly numerous. In 1956 the sisters played key negotiating roles with the government, the Christian Council of Nigeria, the Nigerian Union of Nurses, and the Nigerian minister of health to obtain training grants for nursing students and midwives. Thus, while the Catholics resisted government interference, they also worked with the government to protect Catholic interests.22 By 1966, the Catholic Church had become a “pressure group” in Nigerian politics, and it continued to exert considerable influence in working with the state when the latter challenged Church-controlled education and health care.23 And mission hospitals did expand: in 1960, there were 131 government hospitals, 110 hospitals that Christian missions owned, with another 65 established by private individuals. In southeastern Nigeria, the Catholics had 20 general and maternity hospitals, and 5 were jointly run by the government and the Catholic missions. By then Nigeria had become the showpiece of Ireland’s “spiritual empire.” Fiona Bateman sees this as a second “scramble for Africa.” Just before the Nigerian Civil War began in 1967, the greatest concentration of Irish missionaries in the entire world was to be found there.24

Holy Rosary Sisters in Nigeria In the early twentieth century, Irish priests and nuns went to the mission fields with their own missionary projects.25 Father Shanahan, the founder of the Holy Rosary Sisters, initially determined that these sisters would teach and perform social services, primarily with Igbo women to shape them into strong Catholic Christians. Yet, in the early years, the sisters practiced a semi-cloistered life in the convent, which limited their effectiveness in the community. Strict daily religious exercises were time consuming, and sisters were not allowed to travel or work alone. Eventually they changed their constitutions to allow greater flexibility in travel and accommodations. As noted in Chapter 1, two of the Holy Rosary Sisters’ first school staff members were Nigerians, Maria Anyogu and Clara Oranu, who later became the leaders of the IHMs. To contain the influence of Protestants, a parish priest at Emekuku asked the Holy Rosary Sisters to expand their work to include health care, and in 1931 they opened a hospice for twins and motherless babies. This was similar to a nearby Protestant hospice, but the sisters went further by

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developing it into the first Catholic mission hospital in southern Nigeria. It was staffed by German physicians until Constans ac Sedula freed the sisters to pursue obstetrics in 1936, and a year later they opened a maternity wing. This hospital became an important place for evangelizing, as one sister put it: “One [patient] we had from Ogui is now going to Catechism class and she often comes to the dispensary for medicine and when she does, I usually give her a Catechism examination.” Sisters did not yet view as problematic the fact that patients in their weakened condition were more vulnerable to their proselytizing.26 By 1949, the Holy Rosary Sisters had established three general hospitals and numerous maternity homes in Emekuku, Adazi, Ihiala, Nsukka, and Onitsha.27

MMM in Nigeria An exploration of the MMM in Nigeria starts with their roots in Calabar, where Marie Martin, a nurse and midwife, had gone in 1921 as a lay missionary. When she established her religious congregation in Nigeria in 1937, the MMM followed as surgeons, obstetricians, midwives, nurses, and pediatricians, and they brought their ideas of religious perfection and professional expertise to their work. Their first years were grounded in trial and error, and they frequently had to write home to get advice from Mother Mary. Their strategies included combining acute care hospitals with public health projects. For example, in Nigeria the MMM first began their work in a central, relatively densely populated district where they established an acute care hospital. Eventually they established outstation clinics and opened training schools for Nigerian nurses and midwives, with the goal of working themselves out of a job as quickly as possible. Qualified Nigerian staff, trained by the sisters, then worked in clinics in their own villages. Sisters eventually developed a system of hospitals, maternity clinics, and dispensaries that often extended into the bush areas.28 The method of approach for the MMM also involved learning the local language and opening their hospitals and clinics to all, regardless of religion or ethnicity. Before going to Africa, the sister doctors took special courses at colleges of tropical medicine, and they completed internships at university teaching hospitals in Dublin. Although the MMM undertook medical and nursing work in all areas, their special care was for women

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and children. Working with children and the sick became an extension of women’s domestic roles in the home.29 In describing this gender-specific priority, one of the sisters’ documents noted: Suffice it to say that conditions are such that the number of deaths amongst mothers and infants take an inestimable toll of human life. Obstetrics have therefore, first place in the work of the Medical Missionaries of Mary, for it deals with the natural, essential, Godmade beginning of life. From it follows the care of the child, the entry into the home which eventually leads to the formation of Christian women.30

One of the hospitals that the MMM established was St. Luke’s in Anua, which the MMM began administering in 1937. It focused not only on women and children, however. Starting as a twelve-bed clinic, over the years it developed into a three-hundred-bed facility with departments of surgery, medicine, radiography, obstetrics, gynecology, ophthalmology, and dentistry. In 1955, the hospital admitted 684 maternity patients, 1,766 medical and surgical patients, and 951 children. Sisters performed 1,089 operations and oversaw 14,731 outpatient visits. Significantly, the nuns recorded baptisms that numbered 168, since this report went to the Sacred Congregation of Religious.31 Five years later, admissions had increased, including baptisms that nearly tripled.32 By 1960, the MMM numbered four doctors, two tutors, one clinical instructor, a radiographer, a chemist, a secretary, seven nurses, one teacher, a housekeeper, and a sister with a B.Sc. degree for the laboratory.33 Sister Doctor Margaret Mary Nolan, known as the “Master” at St. Luke’s, described their work in 1962: “Medical Mission work presupposes doing physical good to all who ask us—as Our Blessed Lord did. The question of conversion or change of life may come later.”34 She noted that with modern scientific medicine and nursing, health care practitioners were to use all means possible to save lives. This skilled nun sometimes clashed with male secular physicians over control of the hospital. Still, the fact that Sister Margaret Mary became the executive secretary of the Catholic Secretariat of the Nigeria Medical Department was significant testimony of her standing among her medical colleagues. She also was a fellow of the Royal College of Obstetrics and Gynecology in Ireland.35

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Expatriate secular workers at St. Luke’s included a surgeon, dentist, chaplain, and nurse. Nigerians had a large presence: 23 staff nurses, 125 student nurses, and 146 staff employed in various departments. The Nigerianization of the medical staff was a much slower process than that for nurses, however. Schram notes that most Nigerian men had large families to support and could not do so under the stringent working conditions of a mission hospital. As well, at St. Luke’s the sisters could not get government grants to pay the salaries for physicians, which handicapped them in their recruitment of young doctors.36 Although medical assistants had been active in hospital work in other parts of Africa, that was not the case in Nigeria, where the bulk of the hospital work was done by nurses.37 The MMM made great efforts to establish schools of nursing. As with other colonial nursing schools, reciprocity with Great Britain was a major aim so that Nigerian students would have full recognition in the nursing profession.38 Course syllabi revealed a biomedical approach that focused on body systems, anatomy and physiology, bacteriology, infectious disease, hygiene, dietetics, and cooking.39 By 1958 St. Luke’s listed fifty-eight Nigerian student nurses, forty-four women and fourteen men. The length of training was four years, including one year of a preliminary training course. After much difficulty, which included getting sisters educated as tutors and recruiting students who met the Nursing Council of Nigeria’s requirements, St. Luke’s eventually was recognized as a Grade I Maternity and General Nursing Training School for African student nurses, with reciprocity with hospitals in England.40 St. Luke’s and the Holy Rosary Sisters’ hospital at Emekuku were among the first mission schools to be recognized by both the Nursing Council of Nigeria and the British General Nursing Council.41 Sources of income to St. Luke’s included patient fees and government grants. In 1965, £41,546 from government grants could be compared to income from patient fees of £57,112. Other sources of income included £2,725 in fees and deposits from the training school, but only £287 in gifts and endowments. The largest expenditure was for salary and wages at £68,506. In 1968 the government was paying for trained nurses’ salaries and student nurses (£180 per registered nursing student and £120 per midwifery student), and it also provided bed occupancy grants (£30 per bed). Since it covered 75 percent of the student nurses’ salaries,

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government support was crucial to the mission’s survival. Indeed, without that support, missions could not have kept up with the higher salaries that government hospitals offered nurses. As one mission report noted, “If we put ourselves outside the Govm. Medical Service completely we will be unable to survive at our present level, but will regress and become Nursing Homes for the well-to-do.” Although the amounts were small, sisters always sought money from home and donor societies.42 The MMM also began administration of leprosy facilities in Ogoja (1945), Abakaliki (1946), and Ikom (1952); another general hospital at Afikpo (1946); St. Mary’s in Urua Akpan (1948); a Maternity and Children’s Hospital in Akpa Utong (1954); Sacred Heart Hospital, Obudu (c. 1954); hospitals at Nkalagu (1962), Ibadan (1963) and Ndubia (1966); and numerous general and maternity clinics. After the leprosy settlement opened in Ikom in 1952, the Nigerian government requested the MMM to take over the administration of a 130-bed general hospital and maternity hospital there, Holy Family Joint Hospital.43 The MMM served many ethnic groups, not only the majority Igbos but also minority groups such as the IbibioEfiks, Ik Eks, and Edos. By 1962, their facilities had 11 sister doctors, 5 sister instructors, 20 sister nurses, 48 Nigerian-trained nurses, and 276 Nigerian student nurses and midwives. Many other Nigerian nurses worked in outlying rural settlements.44

Case Study: Nursing and Medical Care during the Nigerian Civil War, 1967–1970 The Civil War that started in 1967 was fought by combatants in the eastern region of Nigeria (renamed Biafra) and the rest of the country. Few Protestant expatriate missionaries were in Nigeria at the time of the war; they had indigenized their hospitals by then, and others left prior to hostilities as a result of the call for a moratorium on Christian missions about that same time.45 This was not the case with the Catholics: 600 expatriate Catholic priests, brothers, and sisters worked in the eastern region. Of the total group, 165 were nuns. Another 200 priests and 180 sisters were in other parts of Nigeria.46 Along with many Irish priests, the Holy Rosary Sisters and the MMM decided to stay with the Biafran people. This decision was left in the sisters’ hands—either with the superior or the

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congregation collectively. Religious orders were free to make their own decisions since they had authority over their own members. No Vatican directives could make them leave or stay, nor could local bishops.47 Economic, ethnic, cultural, and religious tensions led to the war. When Biafra declared itself an independent state, the Federal Military Government of Nigeria regarded this as an act of illegal secession and fought the war to reunify the country. Ireland remained neutral, as did the United States, reflecting the policy of other nations that were unwilling to violate Nigeria’s national sovereignty.48 British policy, however, supported the Federal Military Government forces, which grew out of the desire to continue British influence in eastern Nigeria’s oilfields. By April 1968, Biafrans had flooded into a landlocked enclave entirely surrounded by federal forces who blockaded all the roads. The most vulnerable, particularly children, began showing signs of malnutrition. Medical missioners were right in the middle of this international strife. The World Council of Churches sponsored Protestant relief work, and the international Catholic relief agency, Caritas, also provided food and relief. Both Catholics and Protestants opened more than 650 camps for a million people who had fled to the east.49 The thirty-month war ended in 1970 when the revolt collapsed. The Civil War started just two years after the end of Vatican II and two months after the publication of Populorum Progressio, which advocated for an increased standard of living for all people. By then, the MMM were running nine general and maternity hospitals, two children’s hospitals, four clinics, eleven outstations, three leprosy settlements, three orphanages, two schools of nursing, and five hospitals approved for Grade I midwifery training.50 These facilities served as bases for refugees, patients, and wounded soldiers during the war. To give an example of the mix of personnel who remained at the hospitals during the conflict, one priest wrote about his experiences at the MMM hospital in Afikpo. When it was bombed in July 1967, several sisters were present during the bombing, including the matron, superior, physician, and three nurses. Also present were the superior and three Nigerian Handmaids of the Holy Child Jesus, the congregation founded by Sister Mary Charles Walker, two of their aspirants to the community, an Igbo staff nurse, a laboratory technician, two student midwives, and other hospital staff from Ogoja and Calabar provinces.51

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“Biafran War Diary” Sisters’ documents provide first-person accounts of the impressions of sister nurses and physicians during the war, their activities, the people they tended, accounts of the incidence and character of poverty, and how food shortages could be used as instruments of war. One important document is a diary by Sister Doctor Pauline Dean.52 After receiving her medical education from Liverpool, Sister Pauline joined the MMM and went to Nigeria in 1961. She did postgraduate work in pediatrics in the United States and then worked at St. Mary’s Hospital in Urua Akpan. The diary itemized specific events and incidents in entries for particular days and also reveals her personal thoughts and feelings, such as when and why she felt angry, frightened, confused, or relieved. Working with Sister Pauline were two nurse midwives, Sisters Eugene McCullagh and Elizabeth Dooley; an obstetrician, Sister Doctor Leonie McSweeney; and an administrator, Sister Brigidine Murphy. At the time of the Civil War, St. Mary’s had 150 beds with a large surgical clinic and a Grade I midwifery training school.53 The diary begins there in January 1968. Sister Pauline was an eyewitness to the aerial bombardments of her hospital, and she wrote about the people being killed, roadblocks established by soldiers, and the disease environment in the refugee camps. Indeed, the diary provides a vivid account of the most severe health and nutritional problems of war’s effect. St. Mary’s Hospital was bombed on March 3, 1968, which resulted in four deaths and twenty-one injuries.54 Most of the secular nurses had left the hospital to be with their families, and priests began assisting the sisters with feeding and care of babies. On April 3, Sister Pauline wrote, “Father Johnston did well on night duty leaving everything in ship shape. Father Frawley was heard saying to him last night: ‘Be sure you have plenty of nappies before you go because I ran short last night.’”55 In the eastern region, where military operations were prolonged, farming could not take place and famine reached epidemic proportions. Although the number may have been exaggerated, one Irish priest reported that “more than two million have died as a result of the blockade set up by Nigeria to subdue the secessionists.”56 On April 24, Sister Pauline reported: “To Aba Hospital to try and get blood, but none. Saw and smelt a pile of corpses in the street.” Two days later she held a huge clinic and gave instructions to the priests on how to put on sterile gloves. The

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following day, one of them scrubbed up to help her in the operating room.57 During this period of stress, the existing mission hierarchy seems to have blurred: sister doctors taught priests how to be their assistants. On April 29, Sister Pauline held the “worst clinic ever . . . 123 patients. 50 percent wanted immediate attention. Raced through before going to refugee camp . . . through the bush. . . . But we got lost! Eventually we arrived to find 120 waiting. Five in cardiac failure—many with malnutrition—kwashiorkor—marasmus—gross

anemia—TB.”58

Other

sisters wrote letters back to their home societies detailing their difficult working conditions and the importance of indigenous sister nurses and doctors. As one might imagine, conversion was not a frequent theme.59 One strategy the MMM used was to keep an air raid emergency cupboard and suitcase full of drugs and instruments hidden in their convent, which could be used for emergency operations, since it was not unusual for soldiers to take the hospital’s drugs. At night Sister Pauline went to the hospital in the pitch dark and removed medicine from the pharmacy to put in their trunk so they would have some to take to the refugee camps the next day.60 Although under frequent attack, the sisters also managed to carve out a relief movement. They gave refugee aid by providing shelter and food for orphans and helping them get adopted, distributing clothes to refugees, and growing their own food. The sisters did not avoid all open confrontations with the military regime. On May 9, Sisters Pauline and Eugene had gone to a refugee camp and got lost. They were carrying a young injured boy accused of spying when they were suddenly surrounded by soldiers, told to get out, stand with their backs to the car, and deliver the boy to the soldiers. As Sister Pauline wrote, after a half hour one of the sisters said “in a very demanding voice, ‘Take us to your commander.’” The soldiers did, and the commander recognized Sister Eugene. “Oh, Sr. Eugene,” he said, “how nice to see you. You remember me when I was in your ward after an operation?” He listened to them and allowed all to go back to camp.61 The sisters and their colleagues could not help all the people who were in need. On May 17, 1968, for example, they went to another refugee camp, which Sister Pauline described: “So many sick but had to leave at 6.10. Awful leaving those who had waited all afternoon without being seen.” On May 19 they heard on BBC radio that Port Harcourt had fallen to

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the federal forces. That same day, a sick soldier in the militia arrived at the hospital, and Sister Pauline, with the assistance of three other sisters, performed an appendectomy. Two days later they received a letter stating that all drugs and equipment had to be evacuated by the Biafran army. As some sisters packed, a woman came in with obstructed labor. Sister Pauline delivered the baby “with great trouble. . . . Then did the sluicing—washed the floor—washed the instruments and dried them,” and then started packing the pharmacy. The next day, as two soldiers moved the equipment out, the sisters went to a refugee camp where they again held a large clinic. On June 1, Sister Pauline “felt so awful yesterday after only seeing a hundred people and 200–300 left disappointed and cross.” They returned the next day and saw 136 patients.62 Because of the shortage of sister doctors, sometimes Sister Pauline had to perform an unfamiliar surgical procedure, and she had to read instructions from a textbook as she operated. While this might have led to complications and resentment from local populations, that did not appear to be the case. The nuns also had to negotiate with soldiers, and although diaries and memoirs do not mention if soldiers were Nigerian or Biafran, nuns probably dealt with both. Sometimes friendly soldiers came to visit at the hospital or to warn the sisters of what was to come, while others came to confiscate their supplies.63

“Pangs of Conscience” In the midst of the chaos, the MMM continued to deliver babies, perform Caesarean sections, care for emergency postpartum hemorrhages and combat wounds, and hold clinics in refugee camps. As the battle front neared the hospital, the sisters were constantly on hold for evacuation. On June 10, 1968, Sister Pauline awoke to gunfire at 6 A.M. She held a clinic with the help of two Biafrans and, at the end of the day, “the whole militia camp of twelve turned up for treatment. I was really annoyed,” she wrote, and she tried to get them to go to their commanding officer. When they did not leave, she treated each. She expressed her frustrations thus: “It seems that at every clinic for fear that we should think well of ourselves something like this happens so that we get annoyed and say more than we mean and then have pangs of conscience. But how to be kind and gentle to a gang of healthy men who want medicine for medicine’s sake is beyond me.”64

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On June 26, 1968, the sisters held a clinic amid much shooting from planes flying over them. The next day, Sister Pauline and a woman identified as Mrs. Hogan, a British-trained Nigerian midwife, went to a refugee clinic. Sister Pauline wrote of the malnutrition she observed, “The Ik Ek people looked wild—starved. There were 10 new patients. They put the worst kwashiorkor and marasmus children in a separate place for me to see. . . . The stronger men pushed forward to get things and were told to go back by Mrs. Hogan so that women could come and get a blanket but they wouldn’t go away.”65 While Mrs. Hogan often accompanied the MMM to refugee camps, few details are provided about her work and none of her background. We only know of her activities because Sister Pauline referred to her as “faithful” and mentioned her several times in her diary.66 Yet it is clear that much of the success of the clinics depended on Mrs. Hogan’s actions as intermediary between the sister doctors, nurses, and the Biafrans, not only as “cultural broker,” in Anne Digby and Helen Sweet’s terms, but also as a skilled midwife.67 Because they were staying close to the people, the Catholic sisters and their coworkers all shared the chaos, short tempers, frustrations, and fears that went with working in a war zone. On June 28, Sister Pauline wrote about another clinic: “Just hundreds of patients. Saw 226 very quickly. Nearly all malnutrition. Crowd unruly and noisy.”68 Sister Doctor Deirdre Twomey, Sister Nurse Christine Gill, and Sister Pharmacist Joan Cosgrove were at the Afikpo hospital during the war, were captured, and were accused of supporting the Biafrans. While the sisters were doing surgery, the federal troops arrived and ordered all of the workers and patients who could move to assemble in one room. Sister Christine recalled, “We tried to convince them that we were there for all casualties and that we were on neither side in the war. They eventually went away but returned a few days later in the midst of heavy shelling. It was quite frightening and one of our nurses was killed.” They had to evacuate, march down to the river as the bombs fell, and endure threats and accusations of being collaborators. Eventually they were freed when two priests, one Nigerian and one Irish, interceded on their behalf. They returned to Afikpo, and with the help of the International Red Cross and other agencies, were able to get the hospital up and running to receive the many war casualties pouring in.69

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Not all religious personnel escaped death. One priest who was serving as a chaplain to the armed forces in Bonny was killed in January 1968 during heavy fighting.70 An Irish Presentation Sister, Mother Cecilia Thackaberry, had gone to Port Harcourt in October 1965 and moved to the Holy Rosary convent in Owerri after federal troops captured Port Harcourt. She was helping with relief and medical work in Owerri when she and her driver were killed by a bomb as they were going to a refugee clinic. Another sister and a Biafran male nurse survived that attack.71 During the Civil War, patients often had to wait in long lines to be seen at the clinics and hospitals. The sisters, in fact, had to make difficult decisions by turning away people, who often became angry when they could not get medicine or relief supplies. As the Irish missioners confronted the many challenges from war and dislocation, Sister Pauline and others at St. Mary’s were encouraged to leave. She wrote, “This is really the first time in religious life that my conscience as a doctor tells me one thing.” That message was to stay, because the people in the area had no doctor. Other hospitals were not admitting women and children, the ones most vulnerable to starvation. Sister Pauline truly saw this as a “conflict of conscience.”72 The sisters withdrew on July 2, 1968.

Biafrans as Agents of Relief As professionally trained teachers, nurses, physicians, and midwives, the Holy Rosary Sisters continued to run their hospitals and clinics during the war. Despite their length of time in the country, at first the Biafrans did not trust them. As Bishop Joseph Whelan noted, “All white men were identified with the British, and the British were the enemy.”73 Many of the Irish missioners, however, believed that they belonged with the people with whom they had lived and worked for years. During the peak of the war, one reporter quoted Colonel Chukuemerka Odumegwu Ojukwu, the Catholic Biafran leader: “The worst thing about the Irish is that they are ‘white.’” The reporter added, “And, if skin pigment could be affected by will-power, many of the Irish in Biafra would have changed colour long ago in order to remove the last possible barrier to full identification with the people. . . . Today when you hear an Irish missionary use the word ‘we,’ he doesn’t mean Irish, he means Biafran.”74 This is not a surprising statement. Catholic missioners came to the field with the expectation that they were

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there for the long haul. Sisters stayed for several years before returning home to Ireland; indeed, for many, “home” was wherever they were serving. As in other areas in eastern Nigeria, a contraction of hospital services occurred in the Owerri region where the Holy Rosary Sisters worked. On September 16, 1968, the army of the Federal Military Government of Nigeria took over Holy Rosary Hospital at Emekuku. Just before the army arrived, the sisters and their coworkers evacuated six hundred patients, some ambulatory but others extremely ill. In Owerri, Sister Joseph Therese Agbasiere, the first African Holy Rosary Sister, ran an emergency feeding station for refugees. The story of Sister Joseph Therese provides an illustration of the experiences of African nuns in the Civil War. (See figure 4.1.) As a teacher, she had been in Port Harcourt when it fell to the federal army, and she stayed to evacuate the children. A photograph from Life magazine shows her comforting a mother who had dusted her baby with chalk in an attempt to heal it; the story featured Sister Joseph Therese, Igbo laboratory technicians, and Holy Ghost priests.75 Whereas many other media stories focused only on white men helping needy Biafrans during this period, with no African as spokesperson, the Life story was a clear exception.76 Further evidence of Biafran workers can be seen in a 1968 documentary by Radharc and RTE, an Irish television service. Aimed at an Irish audience, it featured interviews with Irish Holy Ghost Fathers and Holy Rosary Sisters. These sisters maintained their hospital at Ihiala, but it, too was bombed on September 4, 1968. Fifteen people were killed, with the children’s ward hit the hardest. The film illustrates different feeding centers and medical services provided to refugee camps around Owerri, which had been organized under Bishop Whelan. When other sister doctors and nurses had to evacuate Holy Rosary Hospital at Emekuku, they went to Amaimo and began visiting neighboring villages whose population had grown from 12,000 to 24,000 people. The film shows Biafran interpreters aiding them in their medical work. While this documentary highlights the work of white missioners and Caritas, the sponsor of the film, a close examination reveals the many Biafran doctors who assisted at the Ihiala hospital in caring for sick patients and injured soldiers. One night they did 120 operations, many of them amputations.77 In showing Biafran participation in the relief activities, the RTE film also features an interview with a Biafran nun who worked alongside

FIGURE 4.1. Sister Joseph Therese Agbasiere, a Holy Rosary Sister, comforting

a mother who had dusted her baby with chalk in an attempt to heal it. Taken during the Nigerian Civil War by photographer Terrence Spencer. Asset ID # 50655943, Life Picture Collection. Used with permission of Getty Images and the Holy Rosary Sisters, Killeshandra, Ireland.

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other sisters. The nun possibly was Sister Joseph Therese, although inquiries to sisters’ archivists regarding her identity did not reveal a name. When asked by the reporter if she felt hatred toward the federal government, she answered, “As a sister, I should not feel hatred toward them. . . . They just don’t know what they are doing.” She took her religious vows very seriously and worked out of a moral obligation to keep people alive. Yet she also noted, “For Biafrans, this is a war for independence. We are fighting for our rights. . . . If they leave us alone, that is all we want.”78 For this sister, it was important that her fellow Biafrans were meeting the needs of their people. Although the Irish identified with the Biafrans in many ways, they did not shed their other national and cultural identities. This Biafran nun identified with the refugees in ways the Irish could not, and she was a key representative of the Catholic Church to the local people. What the RTE film does not show is that when the nuns began visiting individual families in the villages, Biafrans aided them by making arrangements in advance.79 One report noted: A head man organized each compound on the day of our visit. . . . The danger of air raid had to be kept in mind as bombers crossed daily, bombing the surrounding areas, and other near-by places. Experience had proved that large gatherings were targets, so palm shelters had to be erected to camouflage the centre where we intended working. In this way work was made possible, and though the numbers were big, all the people awaited their turn calmly and quietly, and all were seen.80

The sisters and their Biafran co-workers dressed ulcers and wounds and provided treatment for anemia, malaria, and avitaminosis by giving iron pills and vitamins. They divided the feedings into two sessions daily, with each person getting a drink of milk with Ovaltine, garri, and soup supplemented with Gerber Protein, yams supplemented with oatmeal, American beans, or rice with fish and vegetables. They singled out the most undernourished—expectant and nursing mothers and children under five—for additional feedings. Sisters and Biafrans also made home visits to the elderly and provided food and emergency medical treatment.81

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“We Have Not Lost Hope” As the Holy Rosary Sisters witnessed aerial bombardments of refugees at hospitals and feeding centers, the displacement of large numbers of civilians, and children dying from malnutrition, their feelings fluctuated between discouragement and hope. Sometimes children who had been treated at the hospital for malnourishment and released would return three weeks later in worse shape. A sister wrote after the bombing of the Ihiala hospital: We have planned and worked with all our energies and under a terrible strain to bring life and hope to these people, especially the defenseless children. We felt reward because we could see the effect of our work day by day. Some we had rescued from starvation and death, nourishing them for weeks, until they were almost ready to leave the hospital. Now we see our work being frustrated. But we are not discouraged. Today, the Sisters, Doctors, and Nurses went calmly about their duties. We have not lost hope. The people will return within a few days and we shall continue trying to save them at least from starvation.82

Sister M. Conrad Clifford worked closely with Biafran women to feed refugees who were pouring into camps. Although this Irish sister did not share the ethnicity of the Biafrans, she did identify with their struggle. The RTE documentary shows her singing and dancing the traditional dances with local women, performative evidence that is revealing for what is says about cultural change. Rather than criticizing African dances, as many missionaries had done in the past, this nun joined in an African dance performed with Biafran women.83 In the contested terrain of war, ideas about religion and ritual were changing.

Biafran Airlift The sisters’ documents report the hostilities and the war’s effect, but they do not mention the international politics of the war.84 To get a broader picture of the relief work, Swarthmore College’s Peace Collection proved informative. Documents reveal details of an ecumenical airlift that operated in violation of Nigerian airspace and without Nigerian authority. Transnational links developed under religious sponsorship when, in April

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1968, Protestants and Catholics with financial support from the American Jewish community formed the Joint Church Aid (JCA) group, coordinated by Father Tony Byrne from Caritas. They were joined by the World Council of Churches, Nordic Church Aid, Canairelief, German organizations, and Oxfam. This support across religious and national boundaries was crucial for funding the aid. The airlift they began, often under gunfire, flew in medicines and food to Biafra, even though the Nigerian government had banned outside aid flights. Irish priests also launched a Joint Biafra Famine Appeal, which later became Africa Concern. The International Committee of the Red Cross (ICRC) had an airlift, as well, which the Nigerian government authorized.85 Although the Federal Military Government of Nigeria had offered to supply food to the Biafrans via the river systems, the Biafran government refused because of fear that the food was poisonous. Thus, the airlift became the only remaining lifeline to the outside world for those in the eastern enclave. The agencies used a widened stretch of blacktop road at Uli airport as a night-time landing strip for the supply planes that flew in from neutral sites. The airstrip was bombed periodically, and one ICRC plane was shot down and four relief workers killed. This event and other political actions prompted the ICRC to pull out because of its policy not to intervene unless requested to do so. One priest wrote in 1968 that he “had a grandstand seat on murder” as he viewed seventy-eight dead bodies after a Nigerian airstrike on a market area.86 These factors and the Biafrans’ perception of the situation led the missionaries to fear genocide, and they communicated this to their home societies.87 The early writings of Laurie Wiseberg and John J. Stremlau and newer scholarship by Ndubisi Obiaga, Enda Staunton, Paul Yancho, and Olukunle Ojeleye have described the transnational links, politics, and humanitarianism of organizations that flew the nightly shipments of food and medicines. Ignoring the political questions as much as possible, these relief workers represented their actions as purely humanitarian.88 Nevertheless, in his criticism of Britain for supplying arms to the federal side, Bishop Whelan wrote in his diary: “All we get from the British Government are pious hypocritical platitudes” about protecting their Commonwealth, “yet to this part of the Commonwealth they send only soldiers and tanks to slaughter, to blockade, and to starve.”89 Several Irish priests participated in

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an informational campaign when they went to Ireland and to America to spotlight the famine.90 They presented the people with the choice of saving lives or permitting genocide, and their writings about starvation caused the international community to focus attention on the conflict. What started as a local event became internationalized as Americans and Irish came out strongly in their response to the Biafrans. In the end, thirty-five church organizations in twenty-one countries provided forty million pounds of supplies during the relief operation. One hundred twenty-two Biafrans and thirty-five North American and European JCA workers died during the relief effort.91 In addition to relief activities, other Biafran women also worked to sustain their population. They developed a cross-border trade, or ahia attack, meaning “act of trading,” in which they bought and sold food items behind enemy lines. All proceeds went to support the population. Some women died as they got caught in areas where the war resumed.92 To be sure, there was no unified “Christian” response, because divisions emerged even among Catholics. Some Nigerian bishops and Catholic sisters were sympathetic to the Nigerian side. Sister Leonie McSweeney, who had worked initially with Sister Pauline at Urua Akpan, eventually was sent to a clinic on the federal side.93 In this entangled intersection of relief from many countries, relationships were fraught with tension. One worker stationed at Sao Tome, the coordinating site of relief work, was not sponsored by a church organization, and he reported administrative problems and misinformation on the island. He complained that “Irish fathers stick together,” and the relief operation was becoming “a bloody religious war of personalities with everyone at everyone else’s throat.”94 Another worker was critical of Church workers who assumed the “white man’s burden” in an airlift in which they demanded appreciation. “Why can’t more people realize that the domination of a white religious do-gooder group is equally as deadening psychologically as the Nigerians would be if they were to overrun Biafra. . . . I see another war for Biafrans—that of maintaining independence and strength from us who are helping them.”95

Consequences for Irish Catholic Priests and Sisters The situation worsened for the Irish when, in an effort to mediate a peaceful solution, Pope Paul VI met with rebel representatives in Uganda in

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1969.96 Many federals viewed this as a pro-Biafran act, and it alienated other Catholic missionaries who worked in the federal areas of Nigeria. Some saw the Catholic Church’s commitment as supporting its own institutional interests, believing, for example, that the Vatican was going all out to protect its missionary investment in eastern Nigeria—the largest it had in Africa—and that elements within the Church were trying to make the area a Catholic state. Hostility on the Nigerian side increased as angry crowds resisted the white racial superiority of the Catholic Church and called for its “Nigerianization,” while Nigerian newspapers questioned how loyal a foreign-born church could be. Others portrayed the war as one between Islam and Christianity.97 Some Biafrans continued their ambivalence toward the Irish sisters: as the MMM prepared to leave in July 1968, the midwife, Mrs. Hogan, was “very upset,” but when they said goodbye to one of the chiefs and gave him a gift, he “was not at all upset.”98 Others were troubled that the British, in their estimation, used armaments for the Nigerian army for economic and political gain. After the war was over, one nun (and she may have been American) wrote that Roman Catholic missionaries were not allowed in certain parts of liberated Nigeria. She noted that the ‘“bloody British” were no doubt “gloating over that order. . . . God forgive me—but if I ever hear some limey talk about my country’s involvement in Viet Nam, I’ll poke him in the nose.” She was particularly frustrated about the “very strong anti-Catholic, anti-white sentiments afloat. . . . It is so strange that they are blind to the fact that the missionaries are the only ones that really and truly have their interest at heart. . . . At any rate the Church is really in for it. Our days are truly numbered here.”99 Although from the beginning, sisters’ tasks had been to establish services that local women and men could continue when the sisters moved on, it was not easy during and after the war. Sometimes they expected gratitude when there was none. The Nigerian government was particularly hostile to the sisters, priests, and relief agencies. It scoffed at the word “humanitarian” and argued that the Irish religious workers prolonged the war by feeding the enemy. Even if priests and sisters did not see themselves as political agents, the Nigerian authorities did.100 The government expelled 300 priests and 200 sisters, mostly Irish, including many of the MMM and Holy Rosary Sisters, on the grounds of “illegal entry into Nigeria,”

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TABLE 4.1

Income and Expenditures, St. Mary’s Hospital, Urua Akpan, 1953–1966 Year

Income (£)

Expenditure (£)

1953

3,888

2,732

1955

9,425

8,124

1957

14,067

14,177

1959

19,801

17,629

1961

31,457

29,007

1963

38,361

36,970

1965

70,103

59,441

1966

74,631

52,107

Source: Medical Missionaries of Mary Archives, Drogheda, Ireland.

although eventually a few were invited back.101 This had great political, religious, and professional consequences for the sisters; they lost most of their hospitals and schools of nursing, which was devastating to them.102 The loss of life was incalculable from the war, and financial losses also were huge for the Irish sisters. Table 4.1 shows St. Mary’s Hospital expenditures in the 1950s and 1960s, with income growing from £3,888 in 1953 to £74,631 in 1966, just before the war began. These figures reveal the amount of money turned over to the Nigerian government after the war. It was not just Nigerians who confiscated supplies. One account in 1968 noted about St. Mary’s: “In June 1968 the Biafran Authorities removed all hospital equipment to a village about six miles away,” before the sisters withdrew on July 2.103 Regarding one of their leprosy settlements, the document reported: “When hostilities commenced in July 1967 Ogoja was rapidly overtaken by the Nigerian Army. At that time, the bank account was at Enugu which remained in Biafran hands. The Credit Balance was £5,638. It is not known if this money will be recovered or honoured when hostilities cease.”104

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Nigerian Sisters during the Civil War The strong networks of the Catholic Church could not prevent the Irish expulsion from the country. Despite these losses for the Irish sisters, the Catholic Church had an advantage: the presence of Nigerian women in religious communities. These sisters stayed behind and maintained the Catholic hospitals after the expatriates left. Nigerian nuns had been working among women and girls since the 1930s. As early as 1949, an anonymous priest described the center for the Sisters of the Most Pure Heart of Mary (later the IHM Sisters) at Urualla as “a power-house.” Attached to their convent were a girls’ primary school and a maternity hospital, because the sisters were all trained as nurses or teachers.105 The people of Awgu had built their own hospital in 1954 but could not manage it, and in 1962 the IHM Sisters took it over. Thus when the Civil War started, they had significant health care experience. Several IHM Sisters were interviewed for this book, and they noted that what was most important to their independence and growth was that Archbishop Charles Heerey, their founder, had given them room to develop their own projects and trusted them to use their initiatives to the fullest extent. The IHM Sisters who worked during the Nigerian Civil War were knowledgeable and skilled in their fields; most were Igbo.106 As mission hospitals fell into military hands, the Catholic facilities would have been taken over by the government had the Nigerian sisters not reclaimed them for the Catholic Church. For example, the infrastructure of the 320-bed Holy Rosary Hospital at Emekuku, with its general nurse training school and school for midwifery, was destroyed by the end of the war. Sister M. Therese Njoku, an IHM Sister, worked hard after 1970 to reconstruct the damaged hospital. The IHM Sisters also recuperated, reconstructed, and upgraded other Catholic hospitals to high standards.107 Transnational links helped: because of the lack of physicians, Catholic authorities recruited German doctors. Misereor, the German donor, provided much of the funding, as did local residents and bishops. The schools of nursing and midwifery had to be reopened, reinspected, and reapproved by the Nursing Council of Nigeria. To do so, the IHM congregation provided sister-tutors and principals to teach the courses, and additional sisters went for training in Nigeria and

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abroad.108 One of their publications is noteworthy in describing the IHM Sisters’ plight: From the complete breakdown of order and law-enforcement agency; the drying up of sources of sustenance; the loss of our chief apostolate as the Government took over schools; the sudden deportation of our elders in the Lord’s vineyard and the consequent weight of responsibility it hauled on us. . . . Yet candidates came in increasing numbers within the first decade after that terrible war. Our numbers grew in leaps and bounds and the geographical expansion of our field of Apostolate seemed to keep pace with the increasing number.109

Similarly, the MMM had Nigerian members who stayed in the country after the war, including Sisters Agnes Maria Essien and Veronica Akpan, both nurses. In September 1968, Sister Agnes Maria wrote her Irish superior expressing frustration after the expatriate sisters had to leave. The letter was full of her longing for the sisters to return and the loss of support she felt.110 Jet bombers had strafed St. Luke’s Hospital at Anua earlier in the year, and the hospital was completely evacuated of patients and staff. Civilian employees of the state eventually occupied the staff houses, and the government officially took over St. Luke’s in October.111 At that time, federal authorities appointed their own doctor and matron. The minister of health ensured that qualified Nigerians took control of hospitals, and he chose Sister Agnes Maria as head of the school of midwifery at St. Luke’s. Sister Veronica became deputy matron and eventually matron.112 When an Irish sister was able to return to St. Luke’s in 1969, she wrote her superior back home that it was obvious that the government wanted to keep St. Luke’s open. She quoted one authority who said, “St. Luke’s was the only decent medical set up the last Government left behind them.” This comforted her as she wrote, “So it was not all in vain, I suppose.”113 While she was in Anua, she stayed for Sister Agnes Maria’s final profession of vows. Many of their Anua and “military” friends attended the ceremony at the Catholic Church, which featured a local Ibibio choir and Nigerian drums and rhythms. Sister Agnes Maria was the biological sister of a local chief, and he provided another celebration at his compound. While there, the Irish sister danced to African music and ate local food.114

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In the 1950s and early 1960s, the Catholic Church in Nigeria had its most numerous personnel in terms of black and white members, but whites still overwhelmingly led it.115 This changed after the Civil War. Between 1970 and 1979, the number of indigenous sisters in Nigeria rose from 679 to 1,114.116 In addition to growing numbers of IHM Sisters, the Handmaids of the Holy Child Jesus experienced remarkable growth, as did the Daughters of Mary, Mother of Mercy. The latter had been established in 1961, and by 1981, they had 249 professed sisters, 28 novices, 14 postulants, and 520 aspirants. During the Civil War, the Nigerian Bishop Godfrey Okoye established the Congregation of the Daughters of Divine Love. It grew to 82 professed sisters in 1977 and 142 in the 1980s, with 300 aspirants.117 Nigerianization of both the Catholic Church and its health care facilities had rapidly expanded, which included the leadership of Nigerian sisters. They became a dominant part of the public face of Catholicism.

Transnational Influences, Revisited In analyzing this case study, it must be kept in mind that all the sisters continued to view their care through a Catholic lens: they still attended Mass, passed out rosaries, prayed, and baptized. Sisters strongly believed in their faith and felt responsible for sharing it with others, but their interpretation of mission expanded to include being with the local people in times of great suffering. It has been shown in previous chapters that Vatican II led to many changes in mission, and the ecumenical Biafran airlift probably was a result of greater collaboration among Catholics and others. Yet one can hardly argue that Vatican II had much effect on sisters’ actions during the Nigerian Civil War. In 1968, representatives from the MMM traveled to different countries to discuss the Council’s findings with their other sisters, but they did not go to Nigeria because of the war. Transformation in mission at that time and place was determined more by social and political situations on the ground rather than any official calls for mission reform. Sisters’ relief work in Nigeria resulted from a humanitarian commitment as a crisis response rather than from any well-planned program of social justice, which would come later.118

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As the notion of transnationalism becomes more important to historians, students of transnational religious ties must keep Catholic sister nurses, physicians, and midwives and their work at the local level in mind. During the Nigerian Civil War, their established medical institutions and organizational structures were called upon during the crisis, and they found ways to give care when they could not do so in their usual patterns. They provided not only healing but also shelter, sustenance, rescue, and help for orphans and those fleeing the violence. Mission had expanded to include relief and immediate aid operations.119 Significantly, the sisters were part of a transnational organization with large resources—that of the Catholic Church—and they were beneficiaries of its personnel as well as of an international airlift for food and drugs. Although these transnational links were undoubtedly important, the consequences of the conflict for the Irish were great: the Church could not prevent their expulsion. It was educated Nigerian sister nurses who were available to keep hospitals and schools of nursing in Catholic hands. The Catholic Church had struggled for position and influence in the political life of Nigeria before the war and continued to do so during the conflict as priests engaged in international political activism to rally a global community. The sisters, however, did not start their work in Nigeria with any political agenda, and they never saw their work as feeding the enemy.120 As women, their roles did not include policy making or publicizing the killings to the world; rather they focused on survival as they saw people dying needlessly. Yet the times were ensnared in politics, and it was impossible for sisters to stay above political disputes. As much as they tried to project an objective image, in reading their documents it is not difficult to see that their voices became more critical. As they identified with vulnerable Biafrans, then they became political.121 After the turmoil of the Civil War, many Nigerians turned to churches for spiritual consolation. A 1983 survey in Calabar showed 248 different religious institutions, half of which were locally organized. This included Pentecostal churches, and many were started by women.122 Mission structures expanded to include greater roles for Nigerians who provided needed physical, psychological, and spiritual support. This shift was unquestionably significant.

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Transformation in Mission Other changes in the Catholic mission occurred as a result of the war. The missionary as a spokesperson for humanitarian interests appeared at this time. As Eno Blankson Ikpe asserts, “The role played by the relief agencies in influencing world opinion concerning the Nigerian crisis showed that extra-governmental agencies could play important roles in forming positive opinion on international events and in international crisis management.”123 A new, more militant, generation of relief organizations came about that included the French Médicins sans Frontières (Doctors without Borders) and the group called the Irish Concern.124 At the same time, Catholic missionaries developed a reputation for staying in war zones after other groups left. Many of the Irish sisters never returned to Nigeria, and today the Irish MMM administer none of the hospitals they started before the Civil War. They did, in fact, meet their goal of working themselves out of a job, but it was sooner than many had expected. Yet this was the beginning of new missions for them. The MMM began working in primary health care, and they increasingly sought to tackle the causes of poverty. It is primarily Nigerian sisters who lead mission health care projects in the country now. Clearly, the war brought on a new era. Just as the Irish sisters took on new missions, the Nigerian sisters also had new opportunities. The Catholic Church had been slow to indigenize its clergy, although less so its nurses. With fewer white expatriates in the Church after the war, more Nigerians were ordained as priests, and Nigerian sister nurses, physicians, and midwives filled in the gap for health care workers.125

5 Transnational Collaboration in Primary Health Care

As Catholic missions were transformed in terms of personnel and practices, they also became more open to other cultural practices. In 1962, Sister Doctor Margaret Mary Nolan, a Medical Missionary of Mary (MMM) who worked in Nigeria, noted: “The native doctors have many useful, powerful leaves and herbs at their disposal. In many cases native treatment will save a life, through controlling haemorrhage, or relieving pain and preventing shock. The ill effects seen from these raw drugs, we presume, arise simply because the dosages have never been studied. All this leaves plenty of scope for research workers.”1 As well, Sister Rose Kershbaumer, Medical Mission Sister (MMS) and nurse midwife in several countries in sub-Saharan Africa, recalled that, as the years progressed, “There was more staff. . . . We also became involved a little bit outside of our immediate area. Then we would have groups of traditional healers get together . . . as the countries then began to recognize that there is some good in traditional medicine. And what you have to do is try to eliminate what isn’t good and support what is good.”2 During the colonial era and for some time during decolonization, agents of biomedicine sought to marginalize indigenous medical practices. These agents included not only ministers of the state but also missionaries. In the 1960s and 1970s, however, Catholic missioners featured in this book adjusted their relationships with indigenous healers and eventually began sharing knowledge. This occurred in the context of expanded primary health care endeavors as preventive nursing and 120

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medical strategies increased. The missioners also allied with national organizations such as ministries of health and global actors such as the Christian Medical Commission (CMC) and the World Health Organization (WHO).3 The role of Catholic women religious who helped shape the international agenda for primary health care, the partnerships they negotiated on the ground, and the obstacles they faced during periods of political violence and instability have not been given sufficient attention by historians of medicine, nursing, women, and religion and are the focus of this chapter.

Background: Catholic Missions and Indigenous Medicine To understand the changes taking place in the 1960s and 1970s, it is necessary to review the historical background of Catholic sisters’ writing about medicine and nursing in sub-Saharan Africa. In their early years, sisters uncritically conveyed a sense of Western cultural and medical superiority. Cooperation of both Church and state occurred in attacks on polygamy, “witchdoctors,” and ancestor cults. As one Ghanaian statesman wrote about nineteenth-century missionaries, “You were expected to seek help from the doctor at the hospital, not from the African herbalist, who had come to be styled the ‘witchdoctor’ or ‘medicine man.’ And yet it was the herbalist who throughout the ages had cured our fevers and our diseases.”4 Medicine in sub-Saharan Africa was holistic in practice, with religious beliefs inseparable from healing. Catholic sisters also believed in healing body and spirit, but they assumed that the medical care and religious teachings used in their home societies were universally true and would be appropriate in Africa. This involved eliminating many indigenous customs.5 In 1939, two Medical Mission Sisters (MMS) wrote a booklet for students interested in the mission field. They fashioned an image of a primitive “Other” living in a land of poverty and superstition. Good will and devotion were insufficient to fight the evils of medicine men and “witchdoctors;” only “the best of modern science” could do that.6 This discourse was not unusual for missionaries. By creating a sense of “otherness,” they could justify their interventions.7 Although their rhetoric included the image of a less civilized African, the MMS also cautioned against turning

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Africans into Americans or Europeans. As early as 1939, they endorsed “meet[ing] the people on their own ground,” and using local medicines “without sacrificing science.”8 Specific examples of how to do this, however, were not forthcoming. In 1945, Mother Anna Dengel, founder of the MMS, remained critical of witchcraft and was specific in how to combat it: “The breaking down of pagan superstitions regarding the magical treatment of disease lies to a great extent in the hands of those who understand the natives’ concepts of disease, and the part played by the native medicine man, and who are able to cure disease with rational means, thus simultaneously relieving suffering and dealing a blow to witchcraft.”9 As late as 1966, a priest continued to decry witchcraft at a meeting in Accra, Ghana, at the National Catholic Secretariat’s Department of Health.10 Yet Ad Gentes (On the Mission Activity of the Church, 1965) had made clear that much of what sisters thought was the natural way of doing things was really culturally constructed.11 Women religious questioned their previous assumptions and grew more open to African culture, including indigenous healers. Although I have emphasized the spread of biomedicine by missioners and other Africans, what is less clear is how Catholic missioners could be influenced by Africans. Actual encounters on the ground are described below.

Indigenous Medicine and the Maryknoll Sisters at Kowak Mission, Tanzania Although African healers continued to be part of local healing systems in Tanzania,12 by the 1960s the majority of health care came through government and mission services.13 As Steven Feierman argues, during the colonial era European powers had reshaped African healing in ways that led to the defeat of most indigenous healers. Some were jailed and others killed.14 At the same time, many Africans accepted some biomedical therapeutics. Some showed a preference for injections over oral medicines, and often they demanded them even when they were not therapeutically indicated.15 In the 1960s, the Maryknoll missioners began to take a more sympathetic view of the clinical efficacy of indigenous medicine. Various

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specialists were involved in healing processes in Tanzania, and half of the Kowak patients had been to some type of indigenous healer prior to coming to the sisters. The Maryknolls attempted to comprehend this phenomenon by learning what indigenous medicine offered and how its healers managed certain conditions.16 Then they translated this knowledge for their sisters and to donors back home. In one report to a donor in 1961, a sister explained that the first person usually seen was the village healer, who dispensed herbs, roots, or charms. “Mongangas” (a Swahili word for “doctor”) specialized in herbs and powders but no charms; and “odjouogas,” or witchdoctors, handled many cases that could not be helped by the other options. Mission leaders had always depicted witchdoctors as the main symbol of “pagan” Africa, and the Maryknolls believed the ones in Kowak to be “charlatans.” Yet they did not judge other healers so dismissively. One such healer was a local “Jathak,” who handled abdominal and chest diseases using a knife and cow’s horn. The healer made a small incision over the area in question, placed the horn over the site, and then sucked it to draw out what was perceived as “evil vapors and spirits.” Although nuns sometimes saw patients with infections from this procedure, the sisters also noticed the positive effect of an accurate diagnosis: “A large number of our patients had been to a Jathak prior to their coming to the dispensary, and we were always amazed at the accuracy with which a lobar pneumonia was mapped out by his incisions in addition to enlarged spleens and livers.” One of their household workers had bruised his thigh and first went to see the sisters. He then decided to go to the Jathak near his village, and the sister went with him just to “see the procedure first hand.”17 Regarding the Mongangas, the sister said, “I can only say that I have seen many cases of infant diarrhea ameliorated within a day by one of these practitioners,” many of whom were women. The Tanzanians likened the sisters to Mongangas: “To be examined by a Monganga and especially with a stethoscope,” wrote the sister, “was the hope of every patient that entered the dispensary.”18 Monganga women were friendly to the missioners; as Walter Bruchhausen surmises, female healers did not work for money and thus were more relaxed in working with hospitals and clinics.19 To the sisters, the fact that many Monganga women were Christian was also significant.

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Sisters also inquired about traditional practices from Africans themselves. In trying to understand why Tanzanians preferred to die in their villages, in 1961 a sister asked a headman who told her of the belief that the spirit departs from the person in his or her village. If death occurs in the hospital, the immediate family might be troubled by an angered spirit in the future. Thus, relatives would remove a dying patient from the hospital, by force if necessary.20 Helen Sweet notes that similar understandings of indigenous practices were also recognized by Protestants in the 1960s; thus the Maryknolls’ attitudes were not unique.21 By the mid-1960s, sister nurses were incorporating some indigenous healing measures into their own practice, although on a limited scale. The clinic had a “snake stone,” as one of the sisters called it. Poisonous snake bites were common, and when a patient came with the problem, the sister nurse incised the bite to get it to bleed and then pressed the small black stone into the blood for an hour until it fell off. The therapeutic effect was that it absorbed the poison, and the sisters marveled at how patients’ pain was relieved soon after. They learned this from a Belgian missionary who had incorporated it into his own practice. His instructions were that, after the treatment, they were to boil the stone in water for thirty minutes and when the bubbling stopped, to soak it in milk for two hours. Then they were to rinse it in fresh water and dry it in the open air, after which it was ready for use again. It proved effective for spider bites and bee and wasp stings, as well.22 This sharing of knowledge proved useful as the sisters became more a part of their local communities, living and working among contrasting worldviews about religion and medicine. Some studies have noted that in mission hospitals in the 1950s and early 1960s, foreign physicians, with their esoteric knowledge and effective diagnosis and treatment, set up a hierarchy, with mission medicine having increased authority over local traditions.23 Yet as evidenced at Kowak, Africans continuously went back and forth among multiple treatments. As the people sought an effective therapy for a problem, sometimes they chose the dispensary before they went to indigenous healers, but at other times they opted for the indigenous healer first. Some used both, taking advantage of as many healing opportunities as possible.

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Greater Cooperation between Protestants and Catholics By the 1970s, when Maryknolls were leaving their clinics and integrating with local Tanzanians in their Ujamaa villages, cooperation in other areas was occurring between Catholics and non-Catholics. Transnational links expanded in the 1970s when MMS Doctor Jane Gates co-chaired a Catholic exploratory committee to determine how to work with the Christian Medical Commission (CMC). This occurred after Vatican II, with its emphasis on inter-religious dialogue and more frequent partnerships with people of other religious faiths. The CMC had been created by the World Council of Churches (WCC) in 1968 as a subunit charged with increasing coordination of church-related programs internationally.24 This was a strategic move, since after African independence, secularizing influences on mission hospitals increased when the government became more involved in health care regulation. As Sister Jane noted, Protestant and Catholic missionaries needed each other. Medical costs were rising due to advancements in medical science, and they wanted to prevent duplication of services.25 They also needed a common response to government regulation. A Joint Working Group between Catholics and Protestants was formed to collaborate on many issues, and this was an important turning point for missions. The Joint Working Group produced a series of studies, among them a statement made in February 1970 on “Common Witness and Proselytism” that sought to restore unity among Christians that had been lost over the centuries. The group recognized the growing pejorative understanding of proselytism: “Here is meant improper attitudes and behavior in the practice of Christian witness. Proselytism embraces whatever violates the right of the human person, Christian or non-Christian, to be free from external coercion in religious matters, or whatever, in the proclamation of the Gospel, [and it] does not conform to the ways God draws free men to himself in response to his calls to serve in spirit and in truth.”26 The statement also called for “the defense of human rights and the promotion of religious freedom,” cooperation in the “struggle for the eradication of economic, social, and racial injustice,” and “the limitation of armaments and the restoration and maintenance of peace.”27 Indeed, as civil rights movements were increasing throughout the world and the arms race was escalating, missions, too, were changing. Provision of health

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care became a human rights issue rather than a means to convert. Thus the neutral language used by the Joint Working Group did not connote any particular organized religion. This context of greater collaboration among Catholics and Protestants soon led to cooperation in support of MMS efforts to improve health care for the neediest. Like the other sisters in this study, the MMS had always worked to prevent disease and promote health. Sisters and their African coworkers held outreach clinics where they provided nutrition instruction, health education classes, and immunizations for tuberculosis. In 1969, Sister Camillus Healy, who had been a public health nurse before she joined the MMS, developed an expanded public health program in several Ghanaian villages that included prenatal, newborn, and children-underfive clinics. By 1972, the MMS and local nurses and assistants were developing village nutrition programs based on community needs and supported by local personnel.28 (See figure 5.1.) In 1973, with funds from donors in the United States, Holy Family Hospital in Berekum had a public health building that provided not only mother and child clinics but also those for tuberculosis and leprosy. General nursing and midwifery students rotated through. Because up to eight hundred patients were often seen on some days in the Outpatient Department, the sisters began training local Ghanaians to help with screening.29 In 1974, a worm eradication program began, and malaria suppression medication was available at the clinic. This led to a significant reduction in anemia in children who attended the clinics, from 50 to 12 percent. Sisters also found that Lifebuoy soap, more available to mothers in local markets than the expensive medicines, was helpful for scabies.30 Yet financial burdens increased as a drought occurred in Ghana in the 1970s, and inflation escalated, bringing shortages of essential commodities to the people and to the sisters. A measles epidemic broke out, and malnutrition cases were on the rise. In addition, government salaries had doubled, and government grants to missions had been cut. Consequently, the missions could not keep up. Mission leaders met with representatives from the CMC, the local diocese, and the Ministry of Health in 1975 and again in 1976.31 The MMS brought their experiences in preventive care to the discussions with the CMC, and they participated in joint planning with the aim of better use of resources. The fight against inequities required

FIGURE 5.1. Nutrition class, Berekum, Ghana, 1972. Used with permission of the

Medical Mission Sisters, Fox Chase, Pennsylvania.

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prioritizing comprehensive care to involve not only treatment but also prevention and health promotion, and it started with the community. This involved focusing on problems of the poor, including providing safe water, nutritious foods, and improved sanitation; and training local healers. Because the missions were already located in rural areas, their complexes became the basis of comprehensive primary health care projects.32 The sisters and the CMC also worked with the WHO to develop new priorities for global health that included greater coordination of services and integration with local healing systems.33 Socrates Litsios has detailed the steps the WHO took in joining with the CMC to bring about this new model. For example, the CMC brought to the WHO’s attention the many community projects that were currently being undertaken by missionaries and nongovernmental organizations in Africa, Asia, and Latin America. Their model of community partnerships and their on-the-ground knowledge and connections served as a guide for CMC and WHO when they recommended the inclusion of not only individuals but also communities when considering how resources were to be used to promote health.34 In 1975, the WHO Executive Board introduced a primary health care approach that involved training community health workers. In 1977, the WHO’s Thirtieth World Health Assembly passed a resolution that sanctioned the training of indigenous healers and research in indigenous medicine. The International Conference on Primary Health Care followed in 1978 in Alma Ata in the Soviet Union, where the goal of “Health for All by the Year 2000” was set. This declaration called for a new economic order globally and an integrated approach to health care that utilized all available resources, including indigenous healers. It involved a multipronged strategy with community participation at every level.35 Thereafter, the MMS and MMM increased their participation in primary health care that involved greater collaboration with indigenous healers and local community leaders.

MMS and Primary Health Care Training with Indigenous Healers in Ghana In 1974, the Ghanaian government took on an expanded primary health care role in a context that included an increase in population growth, urbanization, and inflation. It was ready when the Alma Ata Conference was

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held, and the government sent four representatives. As well, MMS Doctor Francis Webster attended. The next step for the MMS was to begin working with representatives from the Ghanaian Ministry of Health, the CMC, WHO, indigenous healers, and indigenous midwives (traditional birth attendants or TBAs).36 Still, expansion of preventive programs was slow. A major goal for the MMS was to find ways to support rural health care without fostering dependency at a time when essential drugs and supplies were scarce and few health professionals were available.37 Furthermore, it had become obvious that an impediment to effective primary health care was the lack of coordination among Western and indigenous practitioners. In 1979, Medical Mission Sister Mary Ann Tregoning (figure 5.2) became

FIGURE 5.2. Sister Mary Ann Tregoning, Ghana, c. 1980. Used with permission of

the Medical Mission Sisters, Fox Chase, Pennsylvania.

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coordinator of Primary Health Care for Holy Family Hospital in Techiman, Building on the policy recommended by the WHO and the National Health Planning Unit of Ghana, the organization responsible for medical coverage to rural areas, Holy Family Hospital began a project to train indigenous healers, the Primary Health Training for Indigenous Healers program or PRHETIH. Sister Mary Ann, serving as coordinator, worked with Peace Corps workers and an anthropologist, D. M. Warren, who had written his PhD dissertation on indigenous healing. They also partnered with a member of the Ghana Association of Psychic and Traditional Healers, an organization founded in the early 1960s to organize various healers across ethnic groups.38 Although indigenous healers provided care to 70 percent of the population in Ghana, they had been ignored by most health policy makers despite the WHO’s endorsement.39 At the PRHETIH program in Techiman, trainers included staff of Holy Family Hospital, those from a local rural health training school, public health nurses, a medical field unit, and staff sanitary inspectors.40 This group became part of a coordinating committee, along with the chief of the herbalists in Techiman, representatives from the Ghana Association of Psychic and Traditional Healers, the queen mother of the priestess-healers, the head of the TBAs, a Peace Corps volunteer, the district medical officer of health, the chief of the priest-healers, and the chief of the “witch-catcher” healers.41 Sister Mary Ann wrote about the program: After the Alma Ata conference, when Primary Health Care [PHC] was formally introduced into Ghana, I became more involved in PHC activities as we started training village health workers and traditional birth attendants. Through the encouragement of an anthropologist who had done his PhD field work with traditional healers in the Techiman area, we began a program with some of the healers in our area. Our team offered a series of classes to the local healers, and they in turn taught us about what they did. This led to mutual referrals between the various practitioners as some of the healers had ways of treating person’s closed fractures that got good results sooner than those treated with casts. They also shared some of their knowledge about local medicinal herbs and plants.42

This mutual exchange of knowledge was one of several options open to policy planners. While some projects involved upgrading indigenous healers’ traditional tasks, others trained them in new strategies. The PRHETIH

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program involved a combination: team members not only trained the healers in new skills but also integrated indigenous and biomedical systems through referrals that went in both directions. In addition, it not only focused on herbalists but also on the spiritual healers.43 Warren, the anthropologist on the team, had conducted his study on Techiman-Bono spiritual ideas about illness and treatment. For centuries, Techiman had been the capital of the Techiman-Bono, an agricultural group that grew cocoa and foods such as yams and corn. Although Catholicism had made some inroads, most of the Bono practiced their own traditional religion. This included the belief not only in natural causes of illness but also in spiritual causes in the context of relationships with families and ancestors; and healing involved multiple connections of social, psychological, and spiritual issues. The body and soul must be in balance to be in good health, and the Bono practiced many rituals to bring about this balance.44 Yet a parallel health care system had grown in Techiman. Holy Family Hospital was the first biomedical health care facility in the area, established by the MMS in 1954. Because of the sisters’ many years of residence in the region, they had established good relationships with the local populace, and their medical approach was already well known. Bono and other ethnic groups chose one and/or the other depending on the ailment. By 1979, however, Holy Family Hospital was taxed beyond its capacity: the year previous to the PRHETIH program, hospital workers had cared for 5,500 inpatients and more than 120,000 outpatients whose diseases were often preventable. Thus, it was a particularly useful site to try out the new project. The PRHETIH team took up the WHO challenge to help solve the region’s local health problems by partnering with indigenous healers who could treat people in the villages. The goal was for the hospital, then, to receive the most serious illnesses.45 Because Warren had access to large numbers of local healers, he was able to introduce them to Holy Family Hospital staff and administrators. The team began work with herbalists, priest/priestess healers, Mallam (Muslim) healers, and “witch-catching” healers, and partnered not only with the Ministry of Health and the Ghana Psychic and Traditional Healers Association but also with the Brong-Ahafo Regional Integrated Development Program planners. This latter group had already created record sheets and training materials for TBAs. The PRHETIH project also involved a pretraining survey of healers regarding their current

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TABLE 5.1

Topics in PRHETIH Program, 1979 Cycle I

Cycle II

Hygiene principles and how to maintain medicinal herbs

How to store medicinal herbs

Oral rehydration

Foods to use in weaning

Spread of disease by houseflies

Family planning

Vaccination

First aid principles

Convulsions

How to recognize jaundice, leprosy, and measles

Nutrition

End of course review

Review of convulsions and nutrition Source: Excerpted from D. M. Warren, G. Steven Bova, Mary Ann Tregoning, and Mark Kliewer, “Ghanaian National Policy toward Indigenous Healers,” Social Science and Medicine 16 (1982):1873–1881.

understandings of disease and therapeutics and what they wanted from the program.46 A fourteen-week pilot training program was carried out with two groups of seven members each, with the topics shown in table 5.1. Some included biomedical information about diseases while others related more to the healers’ own treatments. For example, participants learned how to maintain medicinal herbs, how to combat disease from houseflies, symptoms of dehydration, and how to treat it. Rather than prescribing a red pepper and ginger enema, which often caused seizures, they learned to provide an oral rehydration solution of water, sugar, and salt. For convulsions they learned to give cold water sponging. They also studied family planning, first aid principles, how to store herbs, how to recognize measles and other diseases, and how to use local high protein foods for basic nutrition.47 At the program’s completion, the team held a graduation ceremony at the local community center, with the paramount chief of Techiman giving the keynote speech. Thereafter the team trained three more groups of eight to ten healers each. Over the next two years, with funding from the

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Techiman District Council, eighty healers became PRHETIH graduates. Graduates also went to the Center for Scientific Research into Plant Medicine for internships where they shared their knowledge of herbs with the researchers. To show interest in personal as well as professional lives of the local people, hospital staff frequently attended indigenous healers’ festivals and shared news with one another. The Ministry of Health eventually incorporated the training materials into its own resources for training community health workers. This recognition was different from many of the national health care programs that simply coexisted with indigenous healers.48

The Healers’ Perspective When asked to determine which of the training sessions were most useful, the healers chose hygienic preparation and preservation of herbs, convulsion treatment and rehydration issues, storage of medicinal herbs, and basic first aid. Family planning was last. From their responses, the team members concluded that the sessions that most directly affected healers’ practice were the most popular, especially the ones dealing with herbs. Although several contraceptive strategies were presented, the healers were less interested. Team members speculated it was “because contraception is antithetical to the beliefs and practices of this highly natalistic society.” Indeed, when they asked one of the priest healers, he revealed that providing contraceptive advice was abhorred by his deity, and he preferred referral of questions about contraception to the public health nurse.49 In 1981, a film, Healers of Ghana, showcased the PRHETIH program with the Bono. Sister Mary Ann and Drs. Robert Bannerman of WHO and Kofi Asare Opoku of the University of Ghana Institute of African Studies were featured. It also highlighted a priest healer who wore charms and amulets and carried a religious shrine on his head that contained a venerated spiritual deity. When someone became ill, the deity informed the healer which root or herb or ritual to use for cure. The film is revealing for its scenes of ancient symbols and rituals used in healing, and it also serves as a way to hear the local healers’ voices.50 They could see benefits of the training not only for their patients but also for themselves. One healer noted that because the government respected them and allowed them to

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practice, “our roots and herbs may be preserved so that when we are gone, our knowledge will not disappear.” Indeed, well-trained healers memorized their interventions, and they spread their knowledge through oral communication.51 Government recognition was crucial to their success and it also affirmed their culture. Another graduate of the PRHETIH program stated, “I get more patients now, which brings more money and more recognition.” Furthermore, “We work with the doctors. If I have a patient with a disease I cannot treat, I send him to the hospital. This is good and it will help the nation.”52 To this healer, it was important to recognize the strengths and weaknesses of both systems. As PRHETIH team members wrote, “The traditional healers of Techiman unanimously supported the program from its inception, and by the time the initial survey had been completed healers from outlying villages were asking to be included in future training programs. The common assumption that traditional healers by and large are unwilling to cooperate in such ventures was not the case in the Techiman area.”53 Furthermore, by listening to and observing indigenous ways of healing fractures, Holy Family Hospital workers noted better outcomes than their own procedures. They began referring persons with fractures and also with psychiatric diseases to the indigenous healers. In the latter case, healers came from the same cultural background as the afflicted, and they had similar beliefs about healing and illness. Thus they could contribute more to psychological stability than the biomedical practitioners.54 These healers were active in other ways: several PRHETIH participants pressed the District Council for more and better latrines, which they obtained, while others were instrumental in improving sanitation via village refuse receptacles.55 African scholars also provided information to facilitate understanding of African healing. Dr. Opoku studied the Bono traditional medical system and, as consultant for the Healers of Ghana film, he was able to correct many misinterpretations. As well, throughout the 1970s and 1980s the CMC published a bimonthly journal, Contact, through which it spread knowledge about how to train health workers and indigenous concepts of disease. One of the authors on Ghanaian healing was Bishop Peter Sarpong, who had studied anthropology at Oxford and theology in Ghana and who had become bishop of Kumasi. He described the research that was being done on the clinical efficacy of herbs and how useful they could be in a country with chronic drug shortages.56

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A 1982 issue of Social Science and Medicine published several articles that demonstrated different projects among government and nongovernment health care workers, including the one about the PRHETIH program. As one author noted, “The late 1970s were a major turning point in the long history of the uncomfortable if not antagonistic relationship between ‘modern’ and ‘traditional’ healing systems.”57 Some missions became sites where modern and traditional healers supported each other.

Training Traditional Birth Attendants As noted earlier, the PRHETIH program was unusual in that it focused on indigenous healers, yet far more government and mission programs incorporated TBAs. As Barbara Pillsbury notes, because TBAs dealt with “technical processes of childbirth where their interventions are not particularly alien to modern-sector medical professionals,” many more received training than spiritual healers whose supernatural belief systems were harder to comprehend.58 The Ghanaian Ministry of Health had already begun supporting programs to train TBAs in 1978. Medical Mission Sister Margaret Moran, a pediatric nurse practitioner, had been working at Holy Family Hospital, Berekum, Ghana, since 1969. In 1980, she began a new position as the primary health care field worker. She went to the various villages to meet with people and find out what they wanted in terms of health care. An important part of her work was to teach local Ghanaians how to be community health workers and do well-baby clinics, nutrition education, and sanitation so that they could run their own clinics. She recalled how she built on the primary health care model that the MMS had already been doing: One of our Sister Doctors had studied public health and maternal child health, and we already had antenatal clinics and well-baby clinics working as well as the hospital and outpatient care services. We had trained midwives who had opened their own maternity centers out in the villages, and they were connected with the hospital since they trained there, and they referred to the hospital if they had a complicated case. We had a large network of health personnel known to us.59

From that base, Sister Margaret went to surrounding villages to educate TBAs. Training at first focused on two TBAs from each village who

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were taught sanitary practices, hygienic preparation, signs and symptoms of complications, and nutrition. Sister Margaret found out, however, that those not trained wanted to be educated as well: So then I thought, “Let’s do it another way. Let me train all the TBAs in each of the towns where there were also Community Health Workers (CHW) who had been trained by nurse midwives and myself from the Public Health Department of Berekum Hospital.” We had eight towns where the training was given. Town Health Committees were formed. They included local leaders, the CHW, and the TBAs.60

Toward the end of their training the TBAs revealed that they were sometimes accused of being “witches,” especially if a complication developed with the delivery. Yet they did not consider themselves witches; rather, they were healers. Together, the TBAs and Sister Margaret developed a ceremony to present the TBAs to the town community on the completion of their training, and they invited the whole village to attend. The hands of the TBAs were blessed and each was presented with a lighted candle. A Scripture passage telling of Mary visiting Elizabeth who was with child (Luke 1:39–56) was read. The TBAs then put on a short play depicting the work they were doing to provide a safe delivery. Prayers and congratulations completed the program.61 This symbolism was important. As Sister Margaret recalled, “Ghanaians are very prayerful and very attuned to God. We did ceremonies like this in the towns where there had been training in order to give them [the TBAs] status and . . . show the people they’re connected to the health system, they’re for you, they’re from you, and they’ve been trained.”62 Because traditional Ghanaian medicine regarded spirituality as an important aspect of the healing process, some women viewed the ceremony as harmonious with their own. As Richard Gray notes, some “aspects of Christianity were eagerly accepted and transformed by Africans because this faith was seen to meet not merely the exigencies of modernization but also at least some of the longstanding spiritual needs and demands of African societies.”63 The agency of the TBAs and registered midwives was evident in many ways. In 1979 during a nationwide strike of the Ghana Registered Nurses

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Association over salaries, nurses and midwives did not come to work for five days. At that time, several TBAs left their families and farms to staff sixteen shifts at Holy Family Hospital. Sister Mary Ann described how the TBAs in Techiman covered the maternity department and conducted all the normal deliveries. “When they needed help with a complicated case, they called on one of our midwives who lived on the compound. She went to the department dressed in her regular clothes, ‘hush, hush.’ . . . Nobody saw her when she was there caring for the woman in labor, as she was on strike.”64 By the late 1970s the MMS were reflecting on health care in new ways. They came to appreciate the fact that traditional healers actually had better success rates with some patients. These healers were more capable than the sisters of understanding the cultural causes of mental illness, and the nuns referred their cases to them. As well, based on the sisters’ work for years in the field, they developed an appreciation of the different ways that people viewed illness and healing. With their connections all over the world, the MMS began to use herbal medicines, acupuncture, and acupressure in the Philippines and muscle and reflex therapy in the United States.65 Sister Sheila McGinnis, after working as a nurse in Vietnam, began teaching complementary medicine through the Center for Human Integration in the United States.66

MMS and Primary Health Care in Uganda Whereas the Ghanaian government had embraced primary health care, albeit slowly due to economic constraints,67 the Ugandan government prioritized hospitals. Social scientists have noted, “Unlike many of its neighbours which initiated community-based services and community health worker programmes in the late 1960s and 1970s, Uganda’s expansion of health services into rural areas emphasized the construction of district hospitals.”68 After being a protectorate of Britain since 1894, Uganda gained its independence in 1962. Christians constituted the majority of religious groups in Uganda, but when President Milton Obote abused civil liberties, church groups did not oppose him. Nor did they initially object to Idi Amin when he seized the government in January 1971. Soon after he came

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to power, Amin banned Christian denominations other than Catholics and Anglicans.69 While he expelled Asians and many Americans and British, including some Catholic missionaries, he allowed the Irish to stay. The well-known Catholic bishop was Ugandan, Catholic sisters had taught Amin’s children, and many of the hospitals in Uganda were managed by Irish Catholic sisters.70 By the 1970s, however, as murder and oppression against people of all faiths worsened, the churches became more united against him. The political situation deteriorated in 1976 as a number of Catholic, Anglican, and Muslim clergy were killed. One was Anglican Archbishop Janani Luwum, who was murdered for protesting abuses to the public. As M. Louise Pirouet notes, after 1976 the churches became an “alternative focus of loyalty” as they “dared to question” Amin’s authority.71 The MMS arrived in Uganda in 1962, the year the country gained independence. They opened Virika Hospital in Fort Portal, where they also established the first nursing school in Western Uganda. As in other countries, the sisters held regular safari clinics in more isolated areas.72 (See figure 5.3.) They built upon services for mothers and children that external aid providers and Makerere University professors had led.73 One of the MMS involved in training TBAs was Ugandan Sister Speciosa Babikinamu, an African-born sister who entered the MMS congregation in 1966.74 Sister Speciosa’s mother was a well-known TBA in her village. She recalled that when she was a child, her mother “used to send me to bring water for bathing the mothers in labor. She showed me the herbs she planted near our house. I kept the secrecy surrounding deliveries and I learned quickly.”75 While secrecy had long been a survival tactic for indigenous practitioners, Sister Speciosa also recalled her mother’s religious beliefs about healing. “She told me the mothers in labor pains never cried tears because of their joy in a new baby coming. I watched my mother making mothers laugh during labor, and she used to pray to God, the Giver of Life.” Sister Speciosa became a nurse midwife and an MMS after receiving her education in England and Uganda. She practiced in the MMS hospitals in Kenya, Ghana, and Uganda, and in 1980 she led the TBA program that was adapted by the Ugandan government.76 When she discussed the insights she gained over the years, she noted:

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FIGURE 5.3. Sister Maria Hornung, pharmacist, on medical safari in a Ugandan village, 1964. Used with permission of the Medical Mission Sisters, Fox Chase, Pennsylvania.

I have gained deep insights into the poverty of the sick person. Such poverty is very painful to watch. Most people think in terms of material things and physical pain, but there is “greater pain than meets the eye,” which the person cannot or will not verbalize, such as fear and anxiety, lack of freedom, vulnerability and dependence on others, lack of energy, spiritual pain and fear of death. They may

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be angry with God, with themselves and with others, and in this condition, they can even demand the impossible from others.77

Sister Speciosa’s knowledge of midwifery was especially valued in Uganda because of her combined understandings of African social roots of healing, its holistic practice, the spiritual and physical causes of illness, religious healing, and biomedicine. Hopes for primary health care dimmed in the 1970s during Amin’s violent eight-year rule, when up to 300,000 people died.78 Most health care centers closed, and the people relied on their own indigenous healers or, at great hardship for family members who transported them, they came to Catholic sisters’ hospitals and community health centers. For many years, church missions had been important providers of care in Uganda, and they proved resilient during the conflict, which enhanced the significance of their work.79 Another MMS, Sister Joan Marie Doud, was a nurse midwife who served in Uganda for forty-three years. One time her work involved a dangerous plan with a priest to help transport an endangered doctor out of the country. At other times, she worked closely with Ugandan TBAs, who became a significant part of her practice in primary health care.80 Sister Joan Marie worked at Virika Hospital. Yet the sisters’ plan all along was to eventually turn it over to a local congregation of sisters as the MMS began concentrating more on primary health care.81 Virika Hospital’s nurse training program, which was already recognized by the government, had been supported by the MMS’ transnational links: donations from Holland went for uniforms and equipment, funds from the MMS in the United Kingdom paid for books, and the Swedish Red Cross provided medicines. In 1974, the MMS transferred the hospital to the diocese of Fort Portal, and the Banyatereza Sisters, a Ugandan congregation, took over the management of the facility.82 The process of moving from acute to primary health care was not always smooth, especially during the trying political atmosphere. Sister Dominica Dogge, an MMS from Holland, was the nursing instructor at Virika Hospital in the early 1970s. When her superior decided to transfer Sister Dominica to Rome, a Dutch physician at the hospital objected. He claimed that after the MMS turned over the hospital to the Banyatereza

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Sisters, within two weeks the hospital collapsed. He pleaded to the superior to allow Sister Dominica to stay for several more months to allow a smoother transfer.83 Sister Rose Kershbaumer weighed in on the decision to her superior. While she respected the doctor’s concern, she was “of the opinion Sister Dominica is in a better position to evaluate the situation and make a realistic judgment on whether or not she can be replaced.”84 In writing to the physician, the superior held to her original decision to transfer Sister Dominica. She began by stating her respect for the struggles all hospital administrators were facing during this unstable period, and then she reiterated the history of the sisters’ decision. In 1973, in consultation with other hospitals to prevent duplication of services, the MMS had closed the maternity and adult divisions of Virika Hospital and left it open to pediatric patients only. This led to an outcry by the local population, and when the Banyatereza Sisters took over in 1974, they did so on the condition that it remain a general hospital. The superior continued, This was accepted [by the bishop and local hospital governing board] and a team of six [Banyatereza] sisters was assigned to take charge of the administration, the nursing service, the maternity and some junior positions. At that time they also planned to take responsibility for the nursing school, as soon as they had a sister trained for the position. Therefore, rather than a collapse of the hospital through our withdrawal, it expanded again into a general hospital, through the enthusiasm and dedication of the Banyatereza Sisters.85

The MMS’s need for Sister Dominica in Rome was “immediate and urgent,” and the superior always had the authority to move personnel as she saw best. Furthermore, both Sister Joan Marie and Sister Speciosa had worked with the Banyatereza Sisters for two years as part of the management transfer process. Thus, the superior trusted the Banyatereza Sisters’ competence and knew that they would support the Ugandan government’s priority of acute care. Her decision was final. Sister Dominica, who had many years of teaching experience, provided an orientation for her replacement in the short time allotted to her.86 After the MMS decided that primary health care would be their priority, in 1979 Sister Joan Marie and Sister Speciosa went to Kasanga, where

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the MMS had established a dispensary. The sisters chose Kasanga because it was a remote village in western Uganda, which, due to the violence, had no health care. The sisters lived among the people, worked with a Congolese medical assistant, and taught community health workers and TBAs.87 They treated thousands with tuberculosis, cholera, and malaria and expanded their work into other clinics in outlying areas. Their activities included educational sessions, provision of immunizations, nutritional care, and programs for mothers and children.88

The Medical Missionaries of Mary (MMM) and Primary Health Care in Uganda In 1955 the MMM began administering Kituvo Mission Hospital in Masaka, Uganda, a hundred miles from Kampala. Catholic and other religious health care institutions had historically worked with the Ugandan government in care that was rooted in biomedicine. During the colonial period, a formal partnership developed when the Frazer Commission (1954) recommended that public funding should go to private, including religious, health care facilities. At that time, the Uganda Protestant and Catholic Medical Bureaus were formed to channel public funds to church-owned hospitals and clinics. In 1971, however, after Amin came to power, this formal partnership was disbanded.89 Like the MMS, when scarcity and violence increased in the 1970s, the MMM had programs already running to help the local populace. In the previous few years, like Catholic women’s congregations all over the world, the MMM were reassessing their mission. They aimed to consider “not only . . . what we think needs to be done, but what the people receiving the services feel they need.” Most of the countries in which the MMM worked were represented at the 1968 Commonwealth Medical Conference in Kampala, Uganda. Attendees stressed the need for preventive care and recommended the integration of both government and mission health services. The medical missionaries in attendance, both Catholic and Protestant, all expressed dissatisfactions that were summed up in a report after the meeting. It was becoming more and more difficult to find trained personnel to work in the missions, and the costs of medical care were rising, despite the fact that government grants paid from 30 to 50 percent of

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hospital operations.90 That meant increasing patient fees to such a level that many could not afford them, which resulted in criticism of hospitals as “alien affluent” institutions that did not care for the needs of the poor. For the MMM in particular, “getting out amongst the people first,” one of their goals since their original foundation, was getting lost. Most important, the report noted: In developing countries, more so than others, it is obvious that socio-economic factors such as ignorance, poverty, poor hygiene and malnutrition, play an enormous . . . factor in ill-health. After some time working heroically to treat the resultant disease, one realizes the folly of the situation. Personnel, skill and time and money should be put into sanitation, Health Education, better farming methods, co-operation, education, communications, and improved trading methods rather than a few isolated groups here and there treating the broken down bodies resulting from the disease and malnutrition consequent to these factors.91

Acute Care during Periods of Violence As public health services collapsed in the 1970s, the limited preventive services were especially vulnerable. Acute care services increased as measles and other communicable diseases, preventable through immunizations, rose in the country, as did nutritional problems. As with other displacement situations, mothers and young children were particularly at risk. Although Uganda had run an Infant Malnutrition Research Center in Kampala, this center faltered in the 1970s.92 As a supplement to this facility, the MMM ran a Nutrition Unit in their hospital that, in 1972, admitted 302 children. Significantly, this Nutrition Unit became a model for others to follow, as many international visitors came to observe, including the Ministry of Health from Uganda and visitors from Kenya, Ceylon, England, and Scotland.93 By 1972, the nuns at Kituvo Hospital were experiencing overcrowding and had to transfer patients to hospitals in other cities. The hospital benefited, however, by the arrival of new sisters to replace those going on furlough or whose skills were needed elsewhere. Archival records also show how Kituvo Hospital functioned, in contrast to government

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hospitals, by obtaining medical supplies from international donors. Although they were rarely enough, in 1973 donations from Ireland accounted for most of the income, with others coming from Germany and an unnamed “development” fund. Sisters, long skilled in being economically self-sufficient, also obtained petty cash from the sale of old newspapers, old stamps, clothes, crafts made by the women, and food from the garden.94 Oral feeding programs were crucial to survival for children. In 1973, 267 children were admitted to the Kituvo Hospital’s Nutrition Unit with moderate to severe cases of malnutrition. Most had never been immunized. In addition to providing acute care, sisters did weekly home and community visits in cooperation with local chiefs and health visitors, usually women, where they taught the causes of malnutrition (not so much lack of food but the “wrong kind of food”) and how to use local foods such as “kitobero,” a mixture of bananas, nuts, and dried fish or beans, with its higher protein content.95 The MMM also taught mothers how to teach each other. Transnational knowledge exchange occurred when visitors from the Ugandan Ministry of Health and representatives from Ireland, Scotland, and Rhodesia visited, during which they mutually shared their knowledge.96 Throughout the early 1970s, there was sporadic fighting in the country, but the nuns wrote little about it because they feared being expelled from the country.97 Rather than openly opposing Amin’s regime, they opted to stay in the country and work discreetly by making Church hospitals available as places for refuge and sustenance. Shots were fired in Masaka in July 1974. As one MMM wrote: People “just don’t know from one minute to the next what might happen. There is definite fighting at the Tanzania border where the war began last time as well.” Without supplies to make bread and other items, sisters and other personnel at the hospital relied on matoke, or steamed bananas, considered a “good standby.”98 It was that same year, 1974, that the MMMs as a congregation committed themselves to greater work in community health, preventive medicine, and the social basis of health and disease, rather than solely hospitalbased curative care.99 In late 1978, Amin invaded Tanzania; and within a year his rule ended when Tanzanian soldiers captured the capital of Kampala and forced him

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to flee into exile. Just a few weeks before, Sister Josephine Grealy had arrived at Kituvo Hospital, and she recalled events that occurred in February 1979. Amin’s soldiers surrounded the hospital thinking it would not be attacked. Yet as the Tanzanian army advanced from the border, the sisters at Kituvo Hospital were right in its path. They immediately sent ambulatory patients back to their homes, while ten patients and nine nurses stayed because it was unsafe to return home. Most of the government hospitals closed, and the nuns received wounded soldiers from both sides. Even though a red cross was painted on the hospital roof, the bombs fell as the sisters moved to a nearby Catholic seminary and patients and nurses went to the neighboring Villa Maria Hospital. Significantly, it was local staff, including a laboratory technician and an office staff person, who remained in charge of the hospital. Workmen who lived close by also helped keep watch, and the hospital was never looted.100 As civil war continued intermittently through the 1980s, international Catholic links helped sisters to resupply their hospitals, both in personnel and material. Sisters could maintain personnel because they lived right on the premises and could always work extra shifts. By contrast, government hospital workers often could not get to work due to bad roads and unsafe travel. While funding was always a challenge, the mission facilities had a mix of resources upon which they could rely. In addition to having financial donors, physicians received medication samples from mission-sending groups in Europe and the United States.101 In the early 1980s the MMM hospitals in both Uganda and Tanzania received material from the Salvatorian Mission Warehouse in Wisconsin. This included several shipments of food, canned milk, iron tablets, cough medicines, surgical supplies, hospital sheets and gowns, intravenous supplies, bandages, stretchers, blood pressure cuffs, and toys for the children. Shipments of antibiotics were especially valuable. At one point, forty-five cases of oral and injectable antibiotics arrived in addition to 85,000 antibiotic tablets. The Catholic hospitals also had access to government supplies, although they had to pay. Government hospitals obtained them free of charge.102 By 1980, however, the MMM were clearly shifting their emphasis to primary health care. One sister in Uganda wrote the motherhouse requesting the establishment of a midwifery training school at Kituvo. The sisters there needed trained midwives and students to help staff the hospital’s

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overcrowded maternity and children’s wards.103 After much discussion, the leaders of the MMM denied the request. Training midwives “is not the best we can do with our resources in order to improve most rapidly [emphasis original] the health of the Ugandan people.” Training midwives would only serve a small percentage of maternity patients who were able to come to the hospital. “But what of the other hundreds or thousands who will continue to deliver in their own homes?” Rather, the leaders encouraged the sisters in Uganda to continue training TBAs or other villagers “so that the majority of women can continue to have their babies at home but with greater safety and more hygienically.” The letter hinted that the Ugandan government had not yet committed itself to primary health care and still prioritized hospital construction. Yet if the sisters continued to pour resources into hospitals and nursing schools, then they would “perpetuate an imbalance and in fact an injustice, namely, a first class service for the chosen few who can come to hospital, and chronic illness and often death for those who do not have that privilege.” This was a major change in thinking for the MMM; they continued their commitment to women and children but in different ways.104

Primary Health Care Links Throughout the 1980s, having returned to London, Sister Pauline Dean, whose diary provided such a moving account of the Nigerian Civil War, wrote Primary Health Care Links, a periodical that she regularly mailed to sisters in each of their different communities. These writings were very influential in comminicating the sisters’ changing ideas toward openness to local customs, indigenous healers, and new ways to teach and learn from local populations. Financed by Misereor, the German donor group, the Links addressed questions of access to care; active participation in learning; communication with each other; and low-cost technology. Throughout their publication, the Links stressed the change in mission and listed strategies for dealing with poverty, food problems, and water shortages. Written in her own handwriting with her personal drawings, Sister Pauline’s first link focused on enhancing the sisters’ grasp of the indigenous healer’s role. She reviewed the long history of the MMM in healing. She recalled how “the fame of ‘injection,’ which cured yaws and other acute conditions, soon spread.” The sisters were especially successful in

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helping very sick children, people with severe accidents, and women in difficult labor. By 1981, however, their medical and nursing practice was becoming more reliant on complicated and expensive technology to which only limited numbers of the population had access. One of her captions read, “People have become cases without personalities.” Sisters saw 200 to 400 patients a day in their outpatient departments and only had time to “look quickly at the patient and write a prescription in shorthand.” While people from the Global North were succumbing to new diseases from stress, overeating, smoking, and lack of exercise, she wrote, those in the South “maintained the value of community.” Sister Pauline then quoted from a book on Nigerian indigenous practices and noted that “certain aspects of traditional health care . . . do apply.” She used to scoff at such ideas and asked her sisters to reflect: “Are you likely to listen to someone who scoffs at the things your family taught you to value?” She then recommended sisters read books written by Africans such as Mirau and His Practice. Mirau was a Tanzanian herbalist who wrote about traditional health care, including remedies for 183 conditions. Through this text, sisters could learn how Tanzanians thought about disease. Finally, she instructed the sisters to visit people in their districts and ask them what they do for health care, where they go, what they believe is the cause of various illnesses, and what kind of instructions they receive.105 Primary Health Care Link #3 focused on the value of “Solidarity with the Poor and Oppressed.” Again Sister Pauline asked her sisters to visit local homes and see if people needed care but could not pay. In her own walks, she found that when she went beyond two to three miles, only those who could afford transportation would come to the hospital. She also discussed examples of political, social, and economic situations in countries where there was top-down planning that resulted in acute care receiving most of the financing. A significant feature in Links #3 and #4 was Sister Pauline’s contrast of sisters’ attitudes toward the people: did they have an attitude of superiority, of “know[ing] it all?” Or did they sit down with the people to find out how they could help each other with their difficulties? And whom did they talk with? Was it the local chief, women in agriculture, leading local women and teachers?106 Strengthening understanding about why local customs existed, even those disapproved by outsiders, became Sister Pauline’s goal for Link #5.

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She began this issue with the UNICEF statement to the press on its collaboration with governments to eliminate female circumcision, which angered some African women whose voices were not represented. These women pleaded for those from other countries to obtain greater understanding of factors that contributed to local practices, such as economic exploitation and poverty. A sketch of a mother with her baby strapped to her back accompanied a description of a custom that was beneficial: the close proximity of mother and baby during infancy, which set the foundation for “an emotionally secure person.” Again Sister Pauline recommended reading books and stated, “You will be surprised how much is recorded already.” One was by Corlien Varkevisser, who had lived among the Sukuma people in Tanzania. The author discussed topics such as power relationships, the local economy, religion, and ideas about pregnancy, birth, infancy, and childhood. Varkevisser gave the example that, rather than merely telling a mother about nutrition, it was important to understand local farming and household duties that left women with little time to cook complicated meals.107 Another publication focused on changing sisters’ ways of working with the local people. Rather than undermining local medical practitioners’ knowledge and practices, Sister Pauline suggested, “The teacher is no longer the one-who-teaches but one who is himself taught in dialogue with his students, who in their turn, while being taught also teach. They become jointly responsible for a process in which all grow.”108 Link #16, written in April 1983, provided a guide to help sisters evaluate their roles in primary health care. Did the sisters go where the people lived? Did they respect the culture? Were local community members participating in planning and opening health care sites? Had the sisters trained them in specific health promotion tasks? Did local community members become self-reliant? Did the sisters work with other disciplines such as education and agricultural experts, voluntary agencies, traditional healers, and government? Finally, had their own thinking changed?109 In the same Link, Sister Pauline reported on a successful program in Hanang District, Tanzania, where Sister Margaret Garneti and other MMM trained eight people as village health workers. Eventually 192 trainees attended the classes. Programs occurred over a period of two years, which also included field experiences, refresher courses, an examination, and

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finally, certification to teach, treat minor illnesses, give first aid, supervise the environmental hygiene of the villages, and represent health interests on village committees. Village health workers did nutrition surveys to identify children with malnutrition and gave demonstrations on how to use local foods high in protein. They assisted staff of nearby hospitals in managing mobile maternal and child health clinics. Sister Margaret reported that at the time of writing, 70 percent of the village health workers had stayed with the project for three to five years, without monetary remuneration. Others left to obtain additional education, while some moved into the towns.110 Yet the sisters’ efforts in primary health care were not easy. They faced food scarcities, lack of clean water, problems in arousing enthusiasm among different ethnic groups who lived among each other in the same community, transportation difficulties, and children and adults so ill that acute treatment rather than prevention was needed. This situation required a new way of thinking about training for the mission field. Thus Primary Health Care Link #26, written in December 1987, the last one, focused on different course work for the sisters to consider in their medical and nursing education. Rather than beginning with anatomy and physiology, Sister Pauline suggested they first think about education in living and communicating in groups; skills for listening and dialogue; understanding why poverty and oppression occur in the different regions; what the basis of power is, including women’s roles; and information about unjust land laws. She recommended the sisters read Paulo Friere’s Pedagogy of the Oppressed.111 She also took time to report on one success story of a sister working in Kenya. The sister’s projects began by making contact with chiefs and local villagers to determine who wanted to be trained as village health workers. The people then chose those in their own communities to help the primary health care team. This sister and her team focused on education for the 25 percent of the population that was poor and could not attend clinics. Through her programs, seventeen families had received land and were settled, and 3,417 vaccinations had been done.112 Sisters did not merely read documents and talk about them. They enthusiastically moved into new areas to begin primary health care projects that became self-sustaining. Finally, as the sisters reflected on dealing with the “signs of the times,” their response to Vatican II’s summons, the

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new sign was HIV/AIDS. Their primary health care roles held promise for how to deal with this crisis in the 1980s and beyond.

Change in Mission Catholic sisters were ready to respond when the Alma Ata Declaration of 1978 set primary health care as a major goal. This validated all the work they had previously done. It is clear, however, that curative medicine had taken most of their time, because of the enormous needs and also the wishes of the African people, and it was difficult to implement preventive measures. Charles M. Good notes that as early as the 1940s in Malawi, the London-based Universities’ Mission to Central Africa had begun discussions of preventive strategies and methods to carry them out, but the plans were not implemented.113 The Maude Commission in 1952 also advocated for a shift to focus on preventive medicine in Ghana, but in the immediate independence period curative medicine still prevailed over preventive services. As Patrick Twumasi asserts, more prestige came to the nationalist government if it built hospitals and clinics, and a “new elite” preferred working in cities and towns.114 A 1964 report to the Tanzanian government acknowledged that preventive services were needed but the people demanded curative medicine.115 A heightened focus on prevention would be more enduring in the 1970s, when international agencies became committed to primary health care and increasingly obtained community participation. Sisters’ documents reveal an understanding of the need for more than curative measures if African health needs were to be met. Thereafter, they became involved less in hospital construction and administration and expanded their primary health care initiatives. Feierman asserts that by 1985, however, despite the integration of indigenous healers and biomedicine, overall health in sub-Saharan Africa remained poor. Health promotion activities fell short of international goals of primary health care for all, especially in rural areas. The enormity of health needs was overwhelming, and although missions and governments appropriated financial and human resources, they were not enough. Urban demands for curative care often took most of the total health budgets.116 The CMC also admitted that promotion of primary health care had its disappointments. It did not bring about “the structural

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changes needed to alleviate the poverty that causes much of the world’s ill health.”117 International leaders, along with the growing power of the World Bank, criticized the broad aims of primary health care and instead stressed “selective” primary health care such as vaccinations as the most cost-effective means of medical care for developing countries.118 Yet the excitement of the 1970s was palpable: it had resulted from transnational alliances among people all over the world, including medical missioners, academics, theologians, community workers, and indigenous healers.119 Feierman acknowledges that cooperation did occur among some groups, as has been outlined in this chapter.120 Transnational diffusion of ideas about medicine and nursing flowed in both directions between sisters and Africans. Through their periodicals, including the Maryknolls’ Regional Rustlings, the MMS newsletters, and the Primary Health Care Links by the MMM, Catholic sisters translated information about local customs and indigenous healing strategies to their members all over the world, thereby connecting various parts of the world to one another. African physicians, nurses, midwives, and assistants also translated ideas about prevention to local communities whose healers, in turn, taught American and European sisters new ways to think about healing. Mission hospitals today are staffed primarily with Africans who have accepted biomedical practice and have incorporated it as their own. As late as 2004, one MMM who was Nigerian wrote, “Since I qualified as a medical doctor in Calabar in my Nigerian homeland . . . I realize more and more that the need for orthodox medical practice cannot be over emphasized, especially in developing African countries. I hope the [Medical Missionaries of Mary] keep up the tradition of having Sister-doctors to do this work as we did all through the years.”121 This doctor clearly had internalized expectations of biomedical accomplishments.122 At the same time, local healers, TBAs, and village workers all remain important parts of a community-centered, pluralistic healing system.

6 Appraising Women Religious and Their Mission Work

Disagreements on the nature of mission legacies continue to be central to historians today. This book has taken a transnational approach to assert that Catholic medical and nursing missions had a significant influence on religion, medicine, nursing, and education in sub-Saharan African societies. Clearly, power imbalances existed, since American and European sisters established and initially administered the institutions. As a result of new theologies, changing social and political conditions, and encounters with African populations, however, sisters underwent a major change in the way they thought about and carried out their work. As they engaged in cross-national flows of knowledge, their immersion in their local communities changed their notion of what it meant to be a missionary. Beginning in the late 1930s and extending into the decolonization and independence eras in sub-Saharan Africa, women of the Catholic Church, moved by a call to play a distinct role in the Church’s healing mission, established a new position for themselves that combined religious commitment and medical science. They became heavily involved in the Catholic Church’s health services and eventually in relief and social justice. Religious life allowed vowed, celibate women to easily cross national borders and develop care networks in sub-Saharan Africa and elsewhere. Mother Anna Dengel and others had worked to change a centuries-old policy that prohibited Catholic sisters from practicing medicine, and after 1936, they became surgeons, midwives, and obstetricians. They worked alongside nurses in new initiatives while recognizing, and in many ways, 152

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embracing the power structure of the Catholic Church and what it could provide them. This book has targeted a sample of sisters in particular local circumstances in sub-Saharan Africa to identify the different ways in which they related to individuals, governments, local healers, and international agencies and how their work and their organizations changed radically after World War II. As early as 1945, Mother Anna wrote that sisters’ endeavors to heal would be of little help unless they were accompanied by an attendance upon “basic social and economic structures.”1 Although it took a period of soul-searching and questioning of the very idea of mission, social and economic realities of the people with whom sisters worked became part of the mission focus as did a greater respect for African cultural practices. Sisters established infrastructures for health care in the form of hospitals, clinics, and schools for nurses, midwives, and auxiliaries, and educated indigenous employees who could sustain what the nuns began. A major significance of sisters’ work, then, lay in establishing health care access that eventually came under local control, which provided one answer to the uneven distribution of health care. At the same time, the sisters moved toward closer association with the poor. Their successes and failures help us understand the importance of transnational partnerships that, over time, involved local participants. Their story can facilitate greater understanding of the process of cultural globalization as missioners and those with whom they lived and worked mutually influenced each other.2 These conclusions are further examined in the following discussion.

Themes in Catholic Mission History in Sub-Saharan Africa after World War II When one examines Catholic missioners during the dismantling of empires—the decolonization movement of the 1940s and 1950s and extending into the independence era—distinct themes emerge. First, Catholic mission personnel have globalized.3 Along with the expansion of missions, African, Asian, and Latin American Catholic women’s congregations grew. Although Catholics were slow to indigenize the clergy, by 1951, of the 15,120 women who were sisters in Africa, 4,437 (29 percent) were

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African. This can be compared to 17 percent German, 12.6 percent French, 12.6 percent Belgian (mainly in the Congo), and 10.6 percent Irish. Smaller numbers came from the United States, Italy, Spain, and the Netherlands.4 After the 1970s, American and European religious congregations were not replacing their members from their own countries, and it was at this time that indigenous sisters and lay members became more active. Indeed, Ad Gentes (1965) had affirmed that the entire Church was to be responsible for missions. In Africa, numerous women entered convents as they faced fewer secular opportunities for women: by 1985 there were 38,086 nuns in Africa, a nearly ninefold increase since 1951.5 Since the 1960s and 1970s, growth of all Catholic institutions in Africa has been an indigenous phenomenon. As an example at the local level, by 1984, the number of Tanzanian sisters had grown by 188 percent. They had fourteen local congregations in addition to other sisters in international religious orders, and they had their own Association of Women Religious Superiors of Tanzania. The total number of sisters was 4,175, with Tanzanians comprising 3,475 and expatriates only 700. There were more than twice as many Catholics in 1984 as at independence, and they made up 20 percent of the total population, with the laity playing increasing roles in mission.6 The second theme that emerges in this period is that from the beginning of their work in sub-Saharan Africa, Catholic sisters focused not only on acute care but also on public health. This caused many challenges as they worked in environments that were different from their own backgrounds in Europe or America. Although sister nurses, physicians, and midwives were well trained in colleges and universities, when working in the bush or holding clinics during wartime or other periods of violence, they faced new challenges. Because physicians were in short supply, often sister nurses took on roles that physicians carried out in Europe or the United States. Many also learned to work with Africans who assisted with diagnosis and treatment. By 1985 sisters had shifted their emphasis to primary health care as they increasingly turned over their clinical facilities to Africans. Third, although sisters maintained a gender-separate mission, within their own congregations professional boundaries frequently blurred. Those nuns who became physicians took on roles often assumed by men. They worked as all-female surgical teams, and when necessary, taught priests how to be their assistants in surgery. Yet in the convent, sister

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physicians sometimes lived under the authority of a sister nurse who was superior of the congregation. The religious superior of the hospital often had the last word over the medical director, who often was a nun.7 Fourth, the shifts in the provision of health care both contributed to and were reactions to broader social justice concerns. Prior to the Second Vatican Council, or Vatican II (1962–1965), Catholic missioners were less likely than Protestants to protest human rights abuses such as those in the Belgian Congo.8 Although the Council was extremely important in influencing changes in sisters’ mission, in some ways the missioner sisters were ahead of Vatican II. As Angelyn Dries argues, through their system of team leadership in mission, they foreshadowed Vatican II’s focus on the Church as the people of God.9 These well-educated women worked with the poor in areas of little access to health care, although they had different trajectories in different parts of the world. Especially after the 1960s, women’s religious congregations became more involved in working with local people to meet their own goals, which may or may not have included embracing Catholicism. The Maryknolls, in particular, were influenced by liberation theology amid criticism by conservative columnists and their own hierarchical Church leaders. A change in mission also often occurred in response to social and political situations such as violence and upheaval, which led Catholic missioners to promote humanitarian relief and social justice.10 And it was not just white sisters who worked for humanitarian ends. African sisters from Ghana, Biafra, Uganda, Nigeria, Tanzania, and other countries provided significant avenues for their nations to survive. Fifth, an increasingly secularized environment after African independence witnessed greater involvement of national and international actors in the health care field. At the same time, the change in sisters’ governance structures from one of authoritative control to one based on collaboration, which occurred after Vatican II, enhanced their administrative capabilities.11 Since they ran the hospitals, they were part of the decisionmaking bodies not only within their own congregations but also in the larger health care field, where they worked with secular male leaders in the World Health Organization (WHO) and national ministries of health. And their communal living, large numbers, mobility, and support of each other gave them advantages more isolated Protestant women did not have.

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As unmarried women, Catholic sisters could take risks that women with families could not. They had undergone a disciplined training period in their convents that involved suppression of individual desires in favor of the community.12 They also could rely upon the human and financial resources of a transnational church. Sixth, even before decolonization and independence, indigenous enterprise was increasingly important in the translation of medical and religious knowledge.13 As Dana L. Robert has asserted, “Although academic critiques have typically focused on the ‘foreign’ agency of Christianity,” the work of an indigenous populace has provided “an important counterpoint to interpretations of mission history solely as western imposition.”14 As Catholic sisters built health care institutions, they provided nurse, midwifery, laboratory, pharmacy, and auxiliary training to local populations. An examination of Catholic medical missions on the ground reveals that, from the beginning, Africans helped create and operate hospitals and clinics as nurses, midwives, pharmacists, technicians, and aides. Eventually sisters contributed to the education of black doctors as the latter rotated through mission facilities and went on treks with the nuns. Significantly, Biafran doctors and nurses were at work in feeding centers and hospitals during the Nigerian Civil War. In 1979, indigenous staff remained at Kituvo Hospital in Uganda and kept it from being looted when the Tanzanian army advanced on its way to ousting Idi Amin. As well, African sisters formed networks with other Africans in public health initiatives, especially to help women and children, although the needs were overwhelming and statistics remained grim throughout the twentieth century. Africans translated mission messages and reinterpreted them to meet their own needs. For some, this meant working as a qualified nurse, physician, midwife, certified village health worker, or traditional birth attendant (TBA). For others, it was an opportunity to heal their nation and thereby play an important role in their countries’ futures. Local community leaders became part of village committees that went into homes, held their own clinics to improve health, and linked people to hospitals. Working as cultural brokers allowed Africans to help members of their own communities to intentionally decide what to accept and what to reject in mission medicine. Thus, when Africans adopted or rejected biomedical ideas, they made conscious decisions to do so.

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Importantly, Africans often controlled the terms under which they worked by staging walk-outs or strikes against mission hospitals. It was African families who decided to send their loved ones to Catholic hospitals and clinics, and the numbers of African patients increasingly grew in these facilities. Yet the patients themselves could contest missioners’ control by leaving the hospital and taking their business elsewhere. Although such a move inconvenienced them because they had to travel longer distances, it also negatively influenced the hospital by reducing occupancy rates and damaging its reputation. On the other hand, some Africans protested when mission hospitals closed. By 1985, nuns were working mainly in primary health care, as they had turned over most of their acute care institutions to local workers. The implications of these developments are important. They reveal the significance of lay authority, whether in making decisions about family members or determining which healing system to use. The missioners offered one option; it was the people themselves who chose.15 Seventh, through their teaching, publications, and health care work, sisters represented a notion of modernity that involved the practice of biomedicine in hospitals and clinics styled after the Global North, albeit with a specific religious vision. They transferred this knowledge and their religious values to Africans through their health care institutions and their schools of nursing and midwifery, where they taught about germ theory, anatomy and physiology, surgery, dispensing medications, curing disease, preventive care, and the need for vaccinations. Although by the 1980s African healers were influencing the nuns’ practice, this was not transferred to their schools of nursing, where education based on British standards persisted. Yet the lines between modernity and tradition often blurred. Sisters were never successful in removing indigenous medicine from African society. Despite all their scientific practices, some nuns did use indigenous practices, tolerated others, and learned to work more collaboratively with indigenous healers. Finally, whereas in the early twentieth century European and American Catholic sisters saw Africa as a fertile ground for converts, over time the Catholic mission tradition became more open to ideas not only of social justice but also to cross-cultural exchanges. When the sisters first went to sub-Saharan Africa as missioners, they assumed that local populations had no coping skills of their own and that they “needed” the sisters. The goal of

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development in the late 1960s and early 1970s replaced the rhetoric of civilization and Christian conversion,16 yet even development language aimed to “save” Africa. There was little understanding of the different needs of African countries that were very distinct from each other and from the needs of Americans and Europeans. It occurred to few sisters at the time that those ideas were patronizing and insensitive, and cultural misunderstandings did occur. Many nuns later regretted their assumptions. One Medical Mission Sister (MMS) noted that the sisters “saw our old ways of functioning as subtle tools of manipulation and exploitation, and as a lack of respect for the people with whom we were involved.”17 Another sister who worked in Nigeria regretted her expectation that the Nigerians should assimilate to the Irish model. She bristled at the thought of old terms that are now offensive to her, words such as “living on a dollar a day,” which depicts only poverty and not strength; or “pagan” rather than “traditional religion,” the latter of which gives legitimacy to African faiths.18 In the 1970s, a Maryknoll sister noted, “We came to Katerere [Tanzania] hoping to give of ourselves as well as our gifts, talents, and professional abilities. We rather quickly learned how much we needed them!”19 Like most who felt called to serve others whose cultures were less technologically advanced than their own, Catholic sisters approached their mission clearly expecting that they would be teachers and enlighteners. This would supposedly enrich the lives of the indigenous people. Yet as nuns confronted an unexpected terrain, their experiences with people on the ground helped change their preconceived ideas. As sisters came to recognize the strength and resilience of local populations, their unintended feelings of condescension were replaced by respect and appreciation of the people with whom they worked. Eventually sisters realized that their own lives had been strengthened and enriched by the very people they viewed themselves as serving. In many ways, the “teachers” became the “learners”—learning that character, wisdom, and grace are integral traits available to all human beings, traits that cannot be enhanced by mere education or prosperity. When looking back at their work in 1979, the MMS reflected on the changes in their mission: “Our response to social justice issues stems from our belief in the right and ability of Ghanaians to perceive their situation and the injustices in it, to make choices of response to this . . . to be

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different from us.” Aspects of the MMS’s work were influenced by the socioeconomic and political realities around them. They interacted with the local unions with an increasing respect for the Ghanaians’ priorities and convictions. “Christian presence,” although they struggled with its exact definition, became a priority in mission. As they prepared to leave Berekum, Ghana, they also reflected on their encounters with Ghanaians over the previous thirty years. They indeed were “grateful for the grace to discern the time and the need to withdraw. The riches to us in the encounters are beyond counting.”20 Drought conditions worsened in Ghana in 1983, which led to harvest failures and famine. This resulted in a reevaluation of the Ghanaian economy and the beginning of World Bank Structural Adjustment Programs. These programs co-opted the primary health care programs that had begun after Alma Ata. Still, the MMS worked closely with the WHO and other partners to increase community participation in decision making.21 A clear shift in the way the MMS wrote about their encounters can be seen in a 1988 document. A sister had returned to Ghana forty years after she had helped open a dispensary and hospital there. Indicating an appreciation for African’s veneration of ancestors, this sister stated, “I am very grateful to the Ancestors of Berekum, whose good, kindly, and generous spirits live on in their heirs and followers.”22 This was a far cry from earlier representations of Ghanaians. Dries summarizes the transformations well: after 1965, “Mission zeal, so often concentrated on action, work, and the salvation of ‘souls,’ now seemed misplaced.” Words describing the mission movement focused not on charity by a few altruistic individuals but rather a mission that included the whole Church. Lay missioners had been active since the 1930s, and their leadership particularly increased at this time.23

Outcomes of Mission Endeavors As Richard J. Reid notes, “It is clear that even small investments in public health, whether at the local or national level, can have a major impact.” Although disease remains prevalent in sub-Saharan Africa, since the 1960s infant mortality rates have dropped and life expectancy has risen by several years.24 African countries still have higher infant mortality rates than

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richer countries, but a World Development Report noted that many fewer infant deaths occurred in sub-Saharan Africa in 1986 than in 1960. For example, in Ghana infant mortality fell from approximately 140 per 1,000 to 90 per 1,000. In Nigeria, it fell from approximately 180 per 1,000 in 1960 to 110 per 1,000 in 1986.25 Others have shown how improvements in child health did occur in sub-Saharan Africa after 1950, but at a slower pace than in other countries.26 Many factors have contributed to this outcome. Among those addressed in this book include the establishment of new health care facilities after World War II. As Catholic missioners expanded their health care work at that time, colonial governments also increased social services; and after independence new African governments improved care facilities to enhance the health of their nations. They expanded hospitals, and sisters’ health care facilities supported national goals of the countries in which they worked. Nuns also worked in rural areas where access to health care was more limited than in urban sites. Their dispensaries at mission stations, their acute care hospitals, and their monthly “safari” clinics or “treks” to outlying areas helped promote access to biomedical care for thousands who did not have it. Sisters also established trust that they, indeed, would be available to the local population, even if it meant staying in areas of violence or fording flooded rivers. Certainly the training of local Africans who did health assessments, triage, injections, and preventive teaching enhanced that trust. Africans also shared their own knowledge about local customs and beliefs with the sisters. By the 1970s, however, as hospital costs increased and health care leaders increasingly came to see that disease and poor health were caused by poverty and poor nutrition, sisters’ resources moved toward supporting preventive health. Expansion into primary health care involved collaboration among missions, governments, indigenous healers, international health agencies, and people in their local communities. Because of their previous work in primary health care, their on-the-ground knowledge, and the local and transnational networks they had developed, Catholic sisters and their colleagues were set to care for people when the HIV/AIDS epidemic began in the 1980s. Today, Catholic health services continue to be important in subSaharan Africa but with local professionals at the helm. For example, in

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1977 the MMS handed over Holy Family Hospital in Berekum and their other hospitals in Ghana to local dioceses. They had indeed “Africanized,” with middle and upper-level management and nursing positions in Ghanaian hands and more Ghanaian doctors employed. 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. Biomedical services continued in outpatient, laboratory, x-ray, and physiotherapy departments.27 The hospital remains an integral part of the Ghanaian health system today. In addition, Sister Doctor Fernande Pelletier stayed in Ghana. Fluent in the Twi language, she, too, “Africanized,” as she became a Ghanaian citizen and worked well into her eighties. Another sister who has stayed is Ursula Preusser, and combined, they have eighty-five years in mission.28 In Uganda, the crisis in public health continued into the 1980s and eventually led to greater international assistance from donor groups and the World Bank. Donors were crucial to the financing of projects, but this did not lead to a more integrated health care system. As Joanna Macrae, Anthony Zwi, and Lucy Gilson assert, “the proliferation of projects, in the absence of strategic national policy, further fragmented the organization of the system, and resulted in significant deficiencies in delivery.”29 The MMS continued their presence in Uganda, however. They started a health center in Rubanda in 1988 at the request of the local bishop, and today they provide primary health care in the areas of maternal and child health care, nutrition clinics, HIV/AIDs programs, safe motherhood, and antimalarial programs.30 In terms of personnel, the Catholic Church continues to have a huge presence in Africa, but it is the Africans themselves who make up its leadership. Historically the Church helped fund them, not just from grant agencies such as Misereor but from many other formal and informal networks of donors. According to Paul Gifford, “The Catholic Church in the 1980s was characterized by a dynamic all its own. On the one hand it appeared very Africanized,” yet it also “was so thoroughly controlled from abroad.”31 This foreign involvement is part of the transnational story of Catholic missions. In the past, it was enough for sisters to go to the mission field to save the “pagans” and baptize them. Over time, however, the nuns were

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enormously influenced by the people themselves from whom they had much to learn. Significantly, Vatican II gave sisters the freedom to experiment with new forms of mission, and each congregation searched for the original essence of its work. This was not always easy to do, and discussions ensued among sisters over what priorities to take. For the sisters in this study, mission changed to include serving the most vulnerable and being open to what was occurring at that particular time and place.

Contemporary Challenges in a Global World Taken together, the chapters of this book have analyzed the evolving nature of transnational health care work under religious auspices and can be seen as historical forerunners of contemporary global health.32 Today, mission has expanded to include dialogue and an increasingly broad base of measures to improve health such as ecological sensitivity, security, and social and economic justice. Rather than dealing with threats posed by secularization, which took much of the sisters’ time between 1945 and 1985, other issues have taken priority. As Catholic sisters increasingly turned over their work to Africans, they have not stayed quiet where justice is concerned. The MMM attend to issues of income insecurity, social and economic discrimination, the provision of high-protein foods for children, and other social justice issues. They continue to train TBAs in several sub-Saharan African countries, and they have worked in war-torn areas such as Angola.33 As an example of their work with persons with HIV/ AIDS, their Kituvo Hospital in Uganda runs two programs: one for in- and outpatients, and a mobile program that covers twenty-seven counties. The mobile program employs community health workers to visit the sick where they dispense medicines, listen to patients, and work with 8,000 orphaned children. In 1994, the mobile program treated more than 77,000 patients. It also pays 75 percent of school fees for the orphans, and to generate income, the sisters run agricultural projects.34 Today the MMS work worldwide to cancel unpayable debts of poor countries and to prevent the trafficking of women. They have taken stances against the black market and bribery; they are concerned with the impact of gender-based violence; and they help prostitutes get health care, with a woman doctor running a public health program for this special group. They also participate in

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movements for ecological justice by providing programs for safe water, food, and air.35 A 1981 New York Times article illustrated the changes among the Maryknolls. It reported that the Maryknoll Magazine, “with monthly circulation of about one and one quarter million, has undergone a virtual transformation since the 1960s. . . . Once packed with articles about orphans and conversions, the magazine now takes what Father Newpower called a ‘more analytical approach,’ and carries articles on such subjects as ‘liberation theology’ and the root causes of social injustice.”36 Evangelism had a broader meaning that included being present in people’s lives. Today, Maryknoll sisters continue to be involved in justice and peace programs. They help orphans of parents who died of AIDS grow vegetables and raise animals. And they are advocates for trafficked women, migrants and immigrants, the homeless, prostitutes, and battered women.37

“Reverse Mission” In all their work, women religious maintain community bonds with their sisters from countries around the world, countries that often are affected by U.S. foreign policy. Timothy A. Byrnes describes the Maryknolls and other religious groups who work to change U.S. policies as advancing a “reverse mission.” As they saw their own governments denigrate the dignity of the individual, sisters became more critical. In the 1970s and 1980s, for example, when the Maryknoll sisters informed American citizens back home about the catastrophic results of American foreign policy in Africa and Latin America, their political activities were attempts to change those programs.38 Although sisters were not the ones during the Nigerian Civil War to directly protest atrocities to the United States and the rest of the world, they were members of the larger Catholic Church whose priests carried out the media campaign. Nuns in Nigeria resisted violence by continuing to offer health care in war-torn areas, and they did the same in Uganda. Thus, sisters’ participation in political issues is not new. It has been transformed today, however, as sisters try to change American policies they consider unjust. Income inequality across the globe that undermines human dignity is increasingly a focus; and even as they expand their work to include socioeconomic issues, sisters also have continued their political involvement.39 As an example of sisters working to

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FIGURE 6.1. Medical Mission Sisters in front of the White House, Washington, DC, participating in a justice march, October 1998. Left to right: Mary Zosso, Jane Gates, Janet Gottschalk, Anne Louise Von Hoene, and Rosemary Smyth. Used with permission of the Medical Mission Sisters, Fox Chase, Pennsylvania.

influence policies, in 1998 the MMS protested outside the White House to exert pressure on American political leaders to take action against the World Bank. (See figure 6.1.)

Contraception Another issue having to do with society concerns the support of the Catholic Church’s teaching on contraception. Transnational networks among mission groups, NGOs, and other activists teach prevention measures for HIV/AIDS. Although a key tool is the use of condoms, the Catholic Church teaches that sex should only occur within a monogamous marriage, and anything beyond abstinence in the form of family planning is morally wrong.40 Conflicts within the Church have erupted over how much to pit opposition to birth control against concerns over the spread of HIV/AIDS. The Church’s policy has had huge consequences, and in 2010 Pope Benedict XVI wrote that condoms might be used for disease prevention, such as by male prostitutes. He sparked much controversy, and clarifications soon came out that his words were not to be taken as permission

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for the widespread use of condoms.41 Nevertheless, years before he made his statement, some sisters were counseling patients to use condoms as one means of protection against the HIV/AIDS epidemic. Figure 6.2 shows a sister in South Africa in 2001 who ran a stall that advertised condoms. This shows how far some Catholic sisters were willing to subvert official dogma of the Roman Catholic Church, seeing it as their responsibility to challenge that dogma. Policies are not consistent across sub-Saharan African countries, however. Although the effects of condom use in preventing HIV are well known, in Uganda, where Catholics comprise 49.6 percent of the population, leaders claim that abstinence rather than condom use has actually led to declining HIV rates.42 Yet one study showed a different result: cleaner needle use, not abstinence or condom use, appeared to make the difference.43 Another study showed that in Uganda, the epidemic has been curbed by campaigns promoting the reduction of the number of individuals’ sex partners rather than encouraging condom use.44 Catholic sisters taught abstinence as a means to prevent the disease, and they taught natural family planning for contraception, but as the disease spread, some nuns began informing their patients where they could buy condoms. Other sisters told their patients where they could get contraception advice or tubal ligations, with the full knowledge that there were times when the woman’s life really was at risk from another pregnancy.45

Other Transnational Networks of Women Religious Because transnationalism involves “flows of people,” networks, and connections, shifting demographics give a new meaning to transnational religion.46 Sisters from Africa and Europe have joined together to participate in political issues. Founded by Sister Doctor Lea Ackerman, a group called Solidarity with Women in Distress (SOLWODI) protests the trafficking of women, sex tourism, and arranged marriages. They offer psychological counseling, shelter, and legal support to women, and they network with NGOs and other groups in Africa and Europe.47 As noted earlier, African sisters and those from Asia and Latin America are increasingly taking on the work of the Catholic Church. These women obtain professional training, most in universities, for social work,

FIGURE 6.2. A Catholic nun runs a stall advertising the use of condoms to pre-

vent HIV/AIDS spreading in Pietermaritzburg, KwaZulu Natal, 2001. Photograph by Greg Marinovich/South Photographs. Used with permission of Africa Media Online.

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pastoral ministry, nursing, and medicine. For example, a Nigerian MMM, Sister Sylvia Ndubuaku, has been working in Capim Grosso, Brazil.48 African sisters are also involved in transnational flows of missionary labor to the United States and Europe.49 The IHM Sisters, based in Nigeria, have grown to 900 members, and, because of the decline in vocations in the United States, Italy, England, Ireland, and Germany, they are now sending sisters as missionaries there. Indeed, as Christianity has gained strength in Africa, Africans are becoming more comfortable in spreading it to Europe and the United States. One group of IHM Sisters is in Minneapolis, Minnesota, invited in 2002 by the local bishop. These sisters negotiate many identities as they navigate the American scene. Each sister has her own area of expertise, depending on the needs of the community. Sister Mary Nesta has a master’s degree in social work and theology, and at the time of this writing, she works at Sharing and Caring Hands. With her dual degree, she addresses many spiritual and psychological needs without pushing her Catholicism.50 Working with her is Sister Maria Chinweze Enujiofor. The general area where the sisters work has only a small Catholic population, and many of the clients are Somali. Like Sister Mary Nesta, Sister Maria does not proselytize. “I cannot really bring in my Catholicism,” she notes. Instead, personal witness is important. “Once people see me, they are like ‘Oh, she reminds me of God.’”51 Another IHM Sister, Sister Maureen Bernardine Onovo, is in the process of becoming a licensed practical nurse with a goal eventually to be a registered nurse. Her grandmother in Nigeria was an indigenous midwife whom government hospital nurses often called upon to help with a case. Sister Maureen Bernardine recalled the pluralistic medical system in her country that includes herbalists, government hospitals with biomedicine, and faith healing, and each alone is insufficient to her. Whereas indigenous medicine is problematic in terms of inaccurate dosages, biomedicine only focuses on physical care. Reflecting the holistic view of healing so prominent in Nigeria, she asks, “What about mental health? What about the spirit? What about the mind? All of this—all of them have to come together. . . . If I heal the physical part of me and the spiritual part is still suffering, the body is still sick.” When asked about the influence of white missionaries in her country, she noted, “They brought education. They

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brought a lot of good things to us.” But she also pointed out that many local traditions were lost.52 Sister Nkiruka Okafor is in clinical pastoral education at the University of Minnesota Medical Center and is working on her PhD in pastoral care and counselling. She, too, views much of what happened during the colonial era as a loss of local culture, especially in healing. “We believe in a traditional medicine. For healing to take effect, there must be balance . . . equilibrium. . . . This order is holistic—what I view as holistic healing. . . . We have not yet arrived at the integration of all these at this moment, at this point for me. Africans are still negotiating their culture because of this massive influence and massive overriding with the new tradition.”53 Another IHM is Sister Immaculata Uwanuakwa, who works as a registered nurse at Providence Health Services in Alaska. Like the other sisters in medical missions, she cares for both body and soul. In doing so, she tries to acquire a deep appreciation of the pain and anxiety of the sick, especially those near death. “Sometimes when they see me, they think I’m coming to pray for them. I will tell them, ‘You like me to pray?’ I say, ‘Okay, we pray.’” Yet, “I also give them medication and I do my job too. When I finish, then we pray, whether Catholic or whatever denomination, I don’t care.”54 Whereas American, Nigerian, Irish, and other European sisters maintain their own distinct national identities, they also have connections to their transnational religious organizations.55 The first IHM sisters were trained in the 1930s and 1940s by the Irish Holy Rosary Sisters, and today they address one another as “Sister,” the term commonly used in the United States and Ireland. Yet they also have adapted their own traditions to their Catholicism while at the same time negotiating the complexities of different cultures. Sister Nkiruka noted that Nigerians have had to negotiate “between two traditions that we have come to inherit. We have inherited a traditional way of living, and then we have massive changes that colonization brought about. So I see the period of post-colonization as Africa’s time of massive renegotiations between both cultures. Sometimes there are conflicts; sometimes there are agreements.”56 The IHMs accept the hierarchical structure of the Catholic Church, and they continue to revere their Irish founder, Bishop Charles Heerey. Yet they also are very cognizant of the meaning of Catholicism to them as Nigerian women. Of the three vows of poverty, chastity, and obedience that sisters profess, only the last two have value in Africa. Sister Nkiruka

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explained, “Chastity is a value because African girls and sometimes boys are expected to be chaste before marriage.” Still, one of the difficulties they experience is a lack of understanding from their families that they would choose to live a life of celibacy, because Nigerian women are expected to bear children. Obedience to superiors also is not a problem, because in their culture obeying elders is the norm. But she added: Poverty has no value. . . . Poverty is seen as a lazy man’s last result. You are poor because you are lazy. In African tradition we count riches by what you are able to produce in the land . . . the kind of crop that you’re able to maintain, how you are able to maintain your household, the number of cows you have. For you to be poor means you are lazy. So now for someone to take this as a vow, we take time to explain it to our people; and in our measure of poverty, my people will tell you that the religious are not poor.57

Another distinguishing factor for these Nigerian sisters is that they continue to wear their religious habits, which they see as an expression of their vocations. This gives them an identity as religious women, and many chafe at the thought that American and European sisters have chosen otherwise. Another observable difference from their American and European sisters is that they have brought African worship practices to the Mass. Sister Maria Nkiru noted: “We do a lot of singing and dancing with clapping. It is very loud. Coming here to the United States, it is different [where Mass is celebrated more quietly]. When we say Mass in our community, we have African musical instruments to beat. We have songs too.”58 As Nigerian sisters redefine themselves as women religious and adhere to a hierarchical Church in a new country, they also bring their own understandings of religion to their everyday lives.

Commonalities among Sisters All the sisters in this study focus on meeting the needs of the poor or the vulnerable, and they have never stopped viewing their work as a spiritual calling. They strongly believe in their faith. But their interpretation of mission has expanded to involve engagement across cultures while also participating in multidirectional flows of ideas about care and practice. Their ministries of social justice have demanded independent thought and

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determination. Yet even after Vatican II, the sisters ran into resistance from some bishops and priests who believed community renewal had gone beyond what the Council had in mind. Today, sisters’ mobilization for social justice has led to further tensions with Vatican hierarchical authorities who have resisted many of the nuns’ efforts, fearing their growing independence.59 Although conflict between sisters and clerics over the direction of their communities is not new, Catholic Church patriarchy has become more engrained than ever. The hierarchy has shifted away from the more progressive social justice movements of the 1960s and 1970s and has instead focused firmly on issues related to abortion, contraception, and homosexuality.60 Decisions in these areas may change under Pope Francis, but in 2012 Pope Benedict XVI openly criticized American sisters for emphasizing the Church’s mission to the poor rather than joining the more visible and controversial culture wars. Specifically, the Vatican singled them out as being too timid in advancing the Church’s traditional position on these issues, implying, at least in matters of abortion and contraception, that they were too influenced by modern-day feminists. In particular, the pope criticized the sisters’ challenge to the bishops, the Church’s “authentic teachers of faith and morals” (who are all men). As well, Pope Benedict was concerned about the sisters’ influence in the world: “The current doctrinal and pastoral situation of the LCWR [Leadership Conference of Women Religious] is grave and a matter of serious concern, also given the influence the LCWR exercises on religious Congregations in other parts of the world.”61 In the United States, the LCWR represents 80 percent of the 57,000 Catholic nuns in the county. The LCWR carefully responded to the Vatican without offering to compromise, and the sisters have called for greater dialogue. Such dialogue was soon begun by none other than Pope Francis himself when, in November 2013, he issued his Apostolic Exhortation, Evangelii Gaudium (The Joy of the Gospel). He stated, “I prefer a Church which is bruised, hurting, and dirty because it has been out on the streets, rather than a Church which is unhealthy from being confined and from clinging to its own security.”62 The sisters must have smiled broadly when they heard this exhortation, as it lent credence and approval for what they have been doing for decades.

NOTE ON SOURCES

To examine the complex interactions of sisters with others, I have made original use of a range of evidence, such as missionary diaries, reports, letters, films, books, and magazines, with the understanding that this religious discourse was directed at a particular audience to inspire readers and obtain donations. These sources obscure the reality of individual experience on the ground. Thus I also rely on archival sources in several countries and oral histories of Nigerian, Irish, and American sisters. Although they initially had a single vision of Africans, sisters increasingly imbedded themselves into their host societies. They sought to understand the culture in order to generate appropriate strategies to care for and teach their subjects. In doing so, they generated a vast body of knowledge. Sisters engaged in cross-cultural communication through their practice with patients; books, pamphlets, and teaching documents they wrote for African students; magazines written for their religious orders and Catholic mission boards back home; and correspondence to missionary sisters who worked all over the world. Yet historians not interested in religious change have viewed these records as “propaganda meant to legitimate both evangelization and imperialism.”1 Indeed, sisters who wrote in the 1930s and 1940s certainly encouraged this interpretation. Thus these documents are not without limitations: they embrace one point of view. Until the 1960s, they were gathered in the employ of the imperial powers. And like all sources, they were composed for specific purposes. Missionaries were responsible both to the Catholic Church and to their European and American donors, and documents such as monthly missionary periodicals were published for this audience. Successful ventures and religious rhetoric permeate them.2

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Nevertheless, by reading between the lines, mission documents can be interpreted to clarify meanings not only about the sisters’ views but also about African health care beliefs and practices.3 For example, in a 1939 booklet for the Catholic Students Mission Crusade, the Medical Mission Sisters provided detailed descriptions of health conditions in Africa, China, and India, particularly malaria, sleeping sickness, leprosy, yaws, and malnutrition. They described both indigenous and missionary medical practices, statistics, the African lifestyle, reverence for chiefs and the land, and how chiefs allotted land according to need. Africans might barter with their neighbors, but they would not think of trying to make money at their neighbor’s expense. The capitalist penchant for mining and other economic ventures disrupted this lifestyle; hence, sisters saw their missionary work as undoing the exploitation of Africans by the colonial powers.4 This book has relied on missionary archives that have been neglected by scholars, despite the fact that they have large collections about American and Irish women abroad. The documents provide evidence from the perspectives of local environments in which the sisters worked. Documents also provide information about indigenous cultures, including the physical environment, geography, and specific belief systems. As they interpreted the religions and cultures of their host countries for sisters and relatives back home, some nuns sent to their motherhouses examples of material culture in the form of handmade objects. Examination of these artifacts can reveal not only information about indigenous people but also the missionaries’ own attitudes about them. Missionary documents are also invaluable in documenting accounts of war, epidemics, and famines.5 Sisters also left correspondence, newsletters, and administration records related to the establishment and running of various African hospitals; annual reports; scrapbooks; periodicals; church newsletters; conference documents; maps; minutes of meetings; architectural building plans; financial account books; and auditors’ reports. Diaries and letters from sister physicians, nurses, and midwives working in rural areas and war zones are available, as are materials that document joint church/ government planning of health services. Documents on human resources, the public/private mix, and legislation provide a study of integration and

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the problems that developed when church leaders risked losing what they thought to be their religious identities as they coordinated with national and international governments. Finally, because the sisters were women, their records are very valuable regarding gender issues. Midwifery is particularly interesting because it is a knowledge system that local women controlled in Africa. Sisters documented their work with women in hospitals and bush clinics. A practical problem with missionary sources is that many of the archives are scattered. Some papers have ended up in universities. One of these is Swarthmore University, which has a large collection on peace movements, with many documents on the Nigerian Civil War. It is also difficult to discern from missionary sources how international politics became involved. Thus, to get a broader picture of international connections, national archives in Ireland and the United Kingdom, including Colonial Office Records at Kew, have been explored, as well as government documents in the United States, extensive WHO documents on the web, newspapers, and magazines. Although I give voice to women’s historical power as nurses, physicians, and midwives, white women’s work is privileged in these documents. One has to keep in mind that African voices are mediated by the missionary representations, and silences on African women’s work in missions are marked. One has to ask: “Whose history is recorded? From whose perspective?” Much archival material does not include the silenced: the poor, minorities, and others excluded from power.6 In her discussion of how to read missionary documents, Meredith McKittrick effectively argues that Africans themselves often acted as “mediators . . . between an imported religion and a local context.” Thus it is no longer accepted that Africans were “brainwashed and riddled with false consciousness.”7 One way to find details of Africans is through photographic evidence and the few letters that Africans left. I also have found videos that are now available online, such as that by RTE Archives on Irish life and J. Scott Dodds’s film, Healers of Ghana.8 Although films for documentary purposes were often used as propaganda, they also were helpful in revealing attitudes and interactions among sisters, aid workers, and people on the ground. They also showed actions, gestures, and rhythmic movements as they took place at the time.9

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Instead of assuming that available written archival material speaks for Africans, I also have tried to give African oral sources significance. Some information has been obtained through oral testimonies from African informants that relate their own societies’ histories. With Institutional Review Board approval from the University of Pennsylvania, thirteen oral histories have been collected (seven Irish and American sisters and six Nigerian sisters), many of whom were active in the Catholic hospital movement in sub-Saharan Africa in the latter part of the twentieth century. As with written sources, oral histories are deeply situated and subjective in nature. Oral histories may inform us of the ways the sisters wanted to be remembered by others, or interviewees may have recalled what they now think their actions were in the past.10 At the same time, however, oral sources enabled me to reflect on how sisters thought about disease, the work environment, their professional trajectories, specific belief systems about health and medicine, and the meanings they made of their lives as nuns, nurses, physicians, and midwives.11 Finally, this study has benefited from examining David Henige’s work on oral historiography, with its African-centered emphasis; and feminist methodology with its focus on the recovery of women’s voices.12

NOTES

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MEDICAL MISSIONS IN CONTEXT

1. Adrian Hastings, African Catholicism: Essays in Discovery (London: SCM Press, 1989), 122. 2. Thomas J. Csordas, “Modalities of Transnational Transcendence,” in Transnational Transcendence: Essays on Religion and Globalization, ed. Thomas J. Csordas (Berkeley: University of California Press, 2009), 1; Thomas Bender, ed., Rethinking American History in a Global Age (Berkeley: University of California Press, 2002); N. Glick Schiller, L. Basch, and C. Blanc-Szanton, “Towards a Definition of Transnationalism,” in Towards a Transnational Perspective on Migration: Race, Class, Ethnicity, and Nationalism Reconsidered, ed. Schiller, Basch, and BlancSzanton (New York: New York Academy of Science, 1992). 3. “Amid Explosive Church Growth, African Bishops Meet,” July 28, 2010. http:// www.catholicculture.org/news/headlines/index.cfm?storyid=7022; http://www .speroforum.com/site/print.asp?id=42113. For 1951 statistics, see Joseph McGlade, The Missions: Africa and the Orient, vol. 6, A History of Irish Catholicism (Dublin: Gill and Son, 1967). 4. Dana L. Robert, “World Christianity as a Women’s Movement,” International Bulletin of Missionary Research 30, no. 4 (2006): 180–188; Margaret Mac Curtain, Ariadne’s Thread: Writing Women into Irish History (Galway, Ireland: Arlen House, 2008). 5. Ryan Dunch, “Beyond Cultural Imperialism: Cultural Theory, Christian Missions, and Global Modernity,” History and Theory 41, no. 3 (October 2002): 301–325. 6. For research on cultural brokers, see Ann Digby and Helen Sweet in “Nurses as Culture Brokers in Twentieth Century South Africa,” in Plural Medicine, Tradition and Modernity, 1800–2000, ed. W. Ernstpp (London: Routledge, 2002), 113–129. For similar conclusions among the Navajo in the United States, see David S. Jones, “The Health Care Experiments at Many Farms: The Navajo, Tuberculosis, and the Limits of Modern Medicine, 1952–1962,” Bulletin of the History of Medicine 75, no. 4 (Winter 2002): 749–790.

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7. Anna Dengel, Mission for Samaritans (Milwaukee: Bruce, 1945). First quotation is on p. 1. Second is on p. 3. 8. Ibid., 1. 9. Angelyn Dries, The Missionary Movement in American Catholic History (Maryknoll, NY: OrbisBooks, 1998); Ellen S. More, Elizabeth Fee, and Manon Parry, eds., Women Physicians and the Cultures of Medicine (Baltimore, MD: Johns Hopkins University Press, 2009). 10. Dengel, Mission for Samaritans, 5. 11. Ibid., 115. 12. Dana L. Robert, Christian Mission: How Christianity Became a World Religion (West Sussex, UK: Wiley-Blackwell, 2009); Robert, ed., Converting Colonialism: Visions and Realities in Mission History, 1706–1914 (Grand Rapids, MI: Wm. B. Eerdmans, 2008); Myra Rutherdale, Women and the White Man’s God: Gender and Race in the Canadian Mission Field (Vancouver: University of British Columbia Press, 2002); Hilde Nielssen, Karina Hestad Skeie, and Inger Marie Okkenhaug, eds., Protestant Mission and Local Encounters in the Nineteenth and Twentieth Centuries: Unto the Ends of the World (Leiden: Brill, 2011). 13. Lynn Hunt, “Reframing History,” Chronicle of Higher Education, August 11, 2014, http://chronicle.com/article/Reframing- History/148175/. 14. C. A. Bayly et al., “AHR Conversation: On Transnational History,” American Historical Review 111, no. 5 (December 2006): 1,446. See also Sonya Grypma, “Pushing Boundaries: Transnational Approaches to Global Health History,” in Transnational and Historical Perspectives on Global Health, Welfare, and Humanitarianism, ed. Ellen Fleischmann, Sonya Grypma, Michael Marten, and Inger Marie Okkenhaug (Kristiansand, Norway: Portal Forlag Publishers, 2013), 239–263; and Barbra Mann Wall, “Beyond the Imperial Narrative: Catholic Missionary Nursing, Medicine and Knowledge Translation in Sub-Saharan Africa, 1945–1980,” in Transnational and Historical Perspectives on Global Health, Welfare, and Humanitarianism, ed. Fleischmann, Grypma, Marten, and Okkenhaug, 90–109. 15. Ivan Valuer, “The Roman Catholic Church: A Transnational Actor,” International Organization 25, no. 3 (1971): 479–502; Helen Rose Ebaugh, “Patriarchal Bargains and Latent Avenues of Social Mobility: Nuns in the Roman Catholic Church,” Gender and Society 7, no. 3 (1993): 400–414. Prior to 1983, the terms “nun” and “sister” as well as designations such as “order,” “congregation,” and “community,” had distinct meanings in Canon Law. “Nuns” included those who took solemn vows of poverty, chastity, and obedience, had strict rules of cloister, and devoted themselves completely to prayer and contemplation. “Sisters” took simple vows, had modified rules of enclosure, and performed works of charity in addition to focusing on prayer. A group that took solemn vows was called an “order,” and “community” was used for sisters with simple vows. In this book, the terms will be used interchangeably, as they are in most of the primary and

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secondary literature and in the 1983 revised Code of Canon Law. “Women religious” will also be used. 16. Robert Wuthnow and Stephen Offutt, “Transnational Religious Connections,” Sociology of Religion 69, no. 2 (2008): 209–232; Ryan Johnson and Amna Khalid, eds., Public Health in the British Empire: Intermediaries, Subordinates, and the Practice of Public Health, 1850–1960 (New York: Routledge, 2012); Valuer, “The Roman Catholic Church.” 17. Adrian Hastings, A History of African Christianity, 1950–1975 (Cambridge: Cambridge University Press, 1979); Steven Feierman, “Struggles for Control: The Social Roots of Health and Healing in Modern Africa,” African Studies Review 28, no. 2/3 (1985): 73–147; John Iliffe, The African Poor (Cambridge: Cambridge University Press, 1987, 1992). 18. Timothy A. Byrnes, Reverse Mission: Transnational Religious Communities and the Making of US Foreign Policy (Washington, DC: Georgetown University Press, 2011). 19. Dana L. Robert, “Shifting Southward: Global Christianity since 1945,” International Bulletin of Missionary Research 24, no. 2 (April 2000): 50–54, 56–58; Charles Taylor, A Secular Age (Cambridge, MA: Belknap Press of Harvard University Press, 2007); Peter Berger, Grace Davie, and Effie Fokas, Religious America, Secular Europe? A Theme and Variations (Burlington, VT: Ashgate, 2008). 20. Peter L. Berger, The Sacred Canopy: Elements of a Sociological Theory of Religion (New York: Doubleday, 1967); Linda Woodhead, ed., Peter Berger and the Study of Religion (New York: Routledge, 2001). 21. Jose Casanova, Public Religions in the Modern World (Chicago: University of Chicago Press, 1994); Christian Smith, The Secular Revolution: Power, Interests, and Conflict in the Secularization of American Public Life (Berkeley: University of California Press, 2003); David Martin, On Secularization: Towards a Revised General Theory (Burlington, VT: Ashgate, 2005); Phillip Gorski and Ates Altinordu, “After Secularization,” Annual Review of Sociology 34 (2008): 55–85. 22. Mary Jo Neitz, “Becoming Visible: Religion and Gender in Sociology,” Sociology of Religion 75, no. 4: 513. See also Cheryl Townsend Gilkes, “If It Wasn’t for the Women. . . .” Black Women’s Experiences and Womanist Culture in Church and Community (Maryknoll, NY: Orbis Books, 2000). 23. Dries, The Missionary Movement; R. Elliott Kendall, “The Missionary Factor,” in Christianity in Independent Africa, ed. Edward Fashole-Luke, Richard Gray, Adrian Hastings, and Godwin Tasie (Bloomington: Indiana University Press, 1978), 16–25; Emma Wild-Wood, “Worldwide Shifts in Mission from 1910–2010,” Theology 113, no. 873 (May–June 2010): 163–173. 24. Julius O. Adekunle, “Christianity,” in Africa, Vol. 5: Contemporary Africa, ed. Toyin Falola (Durham, NC: Carolina Academic Press, 2003), 583–602; Wuthnow and Offutt, “Transnational Religious Connections.” 25. Dries, The Missionary Movement.

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26. This Nigerian group is to be distinguished from the many other Immaculate Heart of Mary (IHM) congregations in Europe and the Americas, some of whom also worked in Africa. See also Walter Gam Nkwi, Voicing the Voiceless: Contributions to Closing Gaps in Cameroon History, 1958–2009 (Mankon, Bamenda: Langaa Research and Publishing, 2010), located at Bodleian Library of Commonwealth and African Studies at Rhodes House, Oxford University, Oxford, UK (hereafter cited as RH). 27. Angelyn Dries, “American Catholic ‘Woman’s Work for Woman’ in the Twentieth Century,” in Gospel Bearers, Gender Barriers: Missionary Women in the Twentieth Century, ed. Dana L. Robert (Maryknoll, NY: Orbis Books, 2002), 127–142; Jonathan J. Bonk, ed., The Routledge Encyclopedia of Missions and Missionaries (New York: Routledge, 2007). 28. Elise Whitlock-Rose, “The Ball and the Cross: Catholic Women in Medicine,” Catholic World 141 (May 1935): 222–226; Robert, Gospel Bearers; and Dana L. Robert, American Women in Mission: A Social History of Their Thought and Practice (Macon, GA: Mercer University Press, 1997). 29. Dries, The Missionary Movement; and http://cara.georgetown.edu/caraservices/ requestedchurchstats.html. 30. Barbra Mann Wall, Unlikely Entrepreneurs: Catholic Sisters and the Hospital Marketplace, 1865–1925 (Columbus: Ohio University Press, 2005); Sioban Nelson, Say Little, Do Much: Nursing, Nuns, and Hospitals in the Nineteenth Century (Philadelphia: University of Pennsylvania Press, 2001). 31. Nicola Yeates, “The Irish Catholic Female Religious and the Transnationalization of Care: An Historical Perspective,” Irish Journal of Sociology 19, no. 2 (2011): 77–93. 32. Robert, Christian Mission; Hilary M. Carey, “Introduction: Empires of Religion,” in Empires of Religion, ed. Dana L. Robert, 1–21 (New York: Palgrave Macmillan, 2008). For histories written in the 1960s and 1970s, see J. F. Ade Ajayi, Christian Missions in Nigeria 1841–1891: The Making of a New Elite (London: Longmans, Green, 1965); E. A. Ayandele, The Missionary Impact on Modern Nigeria (New York: Humanities Press, 1966); F. K. Ekechi, Missionary Enterprise and Rivalry in Igboland, 1857–1914 (London: Frank Cass, 1972); and Edward Said, Orientalism (London: Vintage, 1978). 33. Jean Comaroff and John Comaroff, Of Revelation and Revolution, vol. 1: Christianity, Colonialism, and Consciousness in South Africa (Chicago: University of Chicago Press, 1991); Comaroff and Comaroff, Of Revelation and Revolution, vol. 2: The Dialectics of Modernity on a South African Frontier (Chicago: University of Chicago Press, 1997). Others include Andrew Porter, Religion versus Empire? British Protestant Missionaries and Overseas Expansion, 1700–1914 (Manchester: Manchester University Press, 2004); Kevin Ward, “Christianity, Colonialism and Missions,” in Cambridge History of Christianity, vol. 9: World Christianities, 1914–2000, ed. Hugh McLeod (Cambridge: Cambridge University Press 2006), 71–88; James Ferguson, Global Shadows: Africa in the Neoliberal World Order (Durham, NC: Duke University Press, 2006).

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34. William R. Hutchison and Torbin Christensen, eds., Missionary Ideologies in the Imperialist Era: 1880–1920 (Aarhus, Denmark: Christensens Bogtrykkeri, 1982). See also Ann Laura Stoler, ed., Haunted by Empire: Geographies of Intimacy in North American History (Durham, NC: Duke University Press, 2006); Victoria de Grazia, Irresistible Empire: America’s Advance through Twentieth-Century Europe (Cambridge, MA: Belknap Press of Harvard University Press, 2005). 35. Andrew Orta, “‘Living the Past another Way’: Reinstrumentalized Missionary Selves in Aymara Mission Fields,” Anthropological Quarterly 75, no. 4 (Fall 2002): 707. 36. Yves Tourigny of the White Fathers, So Abundant a Harvest: The Catholic Church in Uganda, 1879–1979 (London: Darton, Longman and Todd, 1979); and Michael Gelfand, Christian Doctor and Nurse: The History of Medical Missions in South Africa, 1799–1976 (Sandton, South Africa: Mariannhill Mission Press, 1984). 37. Megan Vaughan, Curing Their Ills: Colonial Power and African Illness (Stanford, CA: Stanford University Press, 1991), 74. 38. Markku Hokkanen, Medicine and Scottish Missionaries in the Northern Malawi Region, 1875–1930: Quests for Health in a Colonial Society (Lewiston, NY: Edwin Mellen, 2007). 39. Inger Marie Okkenhaug, “Refugees, Relief, and the Restoration of a Nation: Norwegian Mission in the Armenian Republic, 1922–1925,” in Protestant Mission and Local Encounters, ed. Hilde, Skeie, and Okkenhaug, 207–232; Ruth Compton Brouwer, Modern Women Modernizing Men: The Changing Missions of Three Professional Women in Asia and Africa, 1902–69 (Vancouver: University of British Columbia Press, 2002); Beth Baron, “Nile Mother: Lillian Trasher and the Orphan of Egypt,” in Competing Kingdoms: Women, Mission, Nation, and the American Protestant Empire, 1812–1960, ed. Barbara Reeves-Ellington, Kathryn Kish Sklar, and Connie A. Shemo (Durham, NC: Duke University Press, 2010), 240–265. 40. See, for example, Stephen Feierman and John M. Janzen, eds., The Social Basis of Health and Healing in Africa (Berkeley: University of California Press, 1992). Newer scholarship includes Anne Digby, Diversity and Division in Medicine: Health Care in South Africa from the 1800s (Oxford: Peter Lang, 2006); Hokkanen, Medicine and Scottish Missionaries; Karen E. Flint, Healing Traditions: African Medicine, Cultural Exchange, and Competition in South Africa, 1820–1948 (Athens: Ohio University Press, 2008); David Hardiman, ed., Healing Bodies, Saving Souls: Medical Missions in Asia and Africa (Amsterdam: Rodopi, 2006); and Claire L. Wendland, A Heart for the Work: Journeys through an African Medical School (Chicago: University of Chicago Press, 2010). 41. J.D.Y. Peel, Religious Encounter and the Making of the Yoruba (Bloomington: Indiana University Press, 2000). Quotation is on p. 413 of David Pratten, “Conversion, Conquest, and the Qua Iboe Mission,” in Toyin Falola, ed., Christianity and Social Change in Africa: Essays in Honor of J.D.Y. Peel, ed. Toyin Falola (Durham, NC: Carolina Academic Press, 2005), 413–439.

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42. Adrian Hastings, The Church in Africa, 1450–1950 (Oxford: Clarendon Press, 1996). 43. Terence O. Ranger, “Godly Medicine: The Ambiguities of Medical Mission in Southeastern Tanzania, 1900–1945,” Social Science and Medicine 15, no. 3 (1981), 261–277; Ranger, “The Local and the Global in Southern African Religious History,” in Conversion to Christianity: Historical and Anthropological Perspectives on a Great Transformation, ed. R. Hefner (Berkeley: University of California Press, 1993), 65–98. See also Norman Etherington, ed., Missions and Empire (Oxford: Oxford University Press, 2008); Mark Harrison, Margaret Jones, and Helen Sweet, eds., From Western Medicine to Global Medicine: The Hospital beyond the West (New Delhi: Orient Blackswan, 2009); Owen White and J. P. Daughton, eds., In God’s Empire: French Missionaries and the Modern World (New York: Oxford University Press, 2012). 44. Ayandele, The Missionary Impact; Elizabeth Isichei, A History of Christianity in Africa: from Antiquity to the Present (Grand Rapids, MI: William B. Eerdmans, 1995); Augustine S. O. Okwu, Igbo Culture and the Christian Missions, 1857–1957 (New York: University Press of America, 2010); John Manton, “Global and Local Contexts: The Northern Ogoja Leprosy Scheme, Nigeria, 1945–1960,” Hist. cienc. saude-Manguinhos [Rio de Janeiro] 10, supl. 1 (2003). doi:10.1590/S0104– 59702003000400010. 45. Lamin Sanneh, “Bible, Translation, and Culture: From the KJV to the Christian Resurgence in Africa,” in Andrea Sterk and Nina Caputo, eds., Faithful Narratives: Historians, Religion, and the Challenge of Objectivity (Ithaca, NY: Cornell University Press, 2014), 187. 46. Dries, The Missionary Movement; Robert, Christian Mission and “World Christianity as a Women’s Movement”; Charles M. Good, The Steamer Parish: The Rise and Fall of Missionary Medicine on an African Frontier (Chicago: University of Chicago Press, 2004); John Illiffe, East African Doctors: A History of the Modern Profession (Cambridge: Cambridge University Press, 1998); Nancy Rose Hunt, A Colonial Lexicon of Birth Ritual, Medicalization, and Mobility in the Congo (Durham, NC: Duke University Press, 1999); Brian Garvey, Bembaland Church: Religious and Social Change in South Central Africa, 1891–1965 (Leiden, the Netherlands: E. J. Brill, 1994); M. Louise Pirouet, “Religion in Uganda under Amin,” Journal of Religion in Africa 11, Fasc. 1 (1960): 25; Jan Kuhanen, Poverty, Health, and Reproduction in Early Colonial Uganda (Joensuun, Finland: University of Joensuu Publications in the Humanities, 2005); Helen Sweet and Anne Digby, “Race, Identity, and the Nursing Profession in South Africa,” in New Directions in the History of Nursing, ed. Barbara Mortimer and Susan McGann, 109–124 (London: Routledge, 2005). Warwick Anderson, “Where Is the Post-Colonial History of Medicine?” Bulletin of the History of Medicine 72, no. 3 (1998): 529. 47. The former title is the Sacred Congregation for the Propagation of the Faith (Sacra Congregation de Propaganda Fide). 48. Bonk, The Routledge Encyclopedia; Hastings, The Church in Africa, 1450–1950.

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49. Hastings, The Church in Africa, 1450–1950. 50. Jesse Page, The Black Bishop: Samuel Adjai Crowther (New York: Fleming Revell Co., 1909), http://www.archive.org/stream/blackbishopsamue00page#page/n5/ mode/2up; James Stewart, Dawn in the Dark Continent or Africa and Its Missions: The Duff Missionary Lectures for 1902 (Edinburgh: Oliphant Anderson and Ferrier, 1903), located at RH; Major F. H. Ruxton, Missions in Africa: Their Political Necessity (London: Universities’ Mission to Central Africa, Central Africa House, n.d.), located at RH; Stephen Addae, The Evolution of Modern Medicine in a Developing Country: Ghana 1880–1960 (Edinburgh: Durham Academic Press, 1997); Bill Freund, The Making of Contemporary Africa: The Development of African Society since 1800 (London: Palgrave Macmillan, 1998). 51. Robert, “Introduction,” Gospel Bearers, 5; Winifred C. Connerton, “Have Cap Will Travel: U. S. Nurses Abroad 1898–1917” (PhD diss., University of Pennsylvania, 2010). 52. Bonk, The Routledge Encyclopedia. The fathers and sisters wore white religious habits, which is thought to have led to their name. 53. Hastings, The Church in Africa, 1450–1950. 54. Ibid. 55. Mary Motte, “Catholic Missionary Movements of the Twentieth Century,” in A Century of Catholic Mission: Roman Catholic Missiology 1910 to the Present, ed. Stephen B. Bevans (Oxford: Oxford Center for Mission Studies, Regnum Books International, 2013), 75–82. 56. Augustine S. O. Okwu, “The Beginning of the Maynooth Movement in Southern Nigeria and the Rise of the St. Patrick’s Missionary Society, 1920–1930,” Journal of Religion in Africa 10, fasc. 1 (1979): 22; Ajayi, Christian Missions in Nigeria. For Rerum Ecclesiae, see http://www.vatican.va/holy_father/pius_xi/encyclicals/ documents/hf_p-xi_enc_28021926_rerum-ecclesiae_en.html. 57. Ruxton, Missions in Africa; and Susan Smith, “Catholic Women in Mission, 1910–2010,” in A Century of Catholic Mission, ed. Bevans, 83–90. 58. Ancilla Kupalo, “African Sisters’ Congregations: Realities of the Present Situation,” in Christianity, ed. Fashole-Luke et al., 122–135; John M Waliggo, Struggle for Equality: Women and Empowerment in Uganda (Limuru, Kenya: Kolbe Press, 2002). 59. http://www.lsosf.org/about_LSOSF.html. 60. Kupalo, “African Sisters’ Congregations”; Coleman Cooke, Mary Charles Walker: The Nun of Calabar (Dublin: Four Courts Press, 1980). See also http://www .hhcjsisters.org/foundation.html. The Sisters of the Holy Child Jesus, founded by Cornelia Connelly, also have an American province. 61. Tourigny, So Abundant a Harvest. 62. Mary-Noelle Ethel Ezeh, Archbishop Charles Heerey and the History of the Church in Nigeria, 1890–1967 (Mumbai: St. Paul’s, 2005). 63. Isichei, A History of Christianity in Africa; Hastings, The Church in Africa, 1450–1950; Hastings, African Catholicism.

NOTES TO PAGES 13–16

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64. Mac Curtain, Ariadne’s Thread, 288. 65. Dries, The Missionary Movement; Edmund M. Hogan, The Irish Missionary Movement: An Historical Survey 1830–1960 (Dublin: Gill and Macmillan, 1990). 66. Isichei, A History of Christianity in Africa; Rosalyn Terborg-Penn and Andrea Benton Rushing, eds., Women in the Africa and the African Diaspora: A Reader (Washington, DC: Howard University Press, 1996); Benjamin Garniss O’Rorke, African Missions: Impressions of the South, East, and Centre of the Dark Continent (London: Society for Promoting Christian Knowledge, 1912), located at RH. 67. Fiona Bateman, “Ireland’s Spiritual Empire: Territory and Landscape in Irish Catholic Missionary Discourse,” in Robert, ed., Empires of Religion, 267–287. Quotation is on p. 273. See also Francisco Gallego and Robert Woodberry, “Christian Missionaries and Education in Former African Colonies: How Competition Mattered,” Journal of African Economies 19, no. 3 (2010): 294–329. 68. Freund, The Making of Contemporary Africa; Hastings, A History of African Christianity, 1950–1975; Isichei, A History of Christianity in Africa; Bonk, The Routledge Encyclopedia. 69. Feierman, “Struggles for Control.” 70. Frederick Cooper, Africa since 1940: The Past of the Present (New York: Cambridge University Press, 2002); A. Kabou, What If Africa Refused Development? (Paris: L’Harmattan, 1991); Toyin Falola, The Power of African Cultures (Rochester, NY: University of Rochester Press, 2003). 71. See, for example, Brouwer, Modern Women Modernizing Men, 86. 72. Jones, “The Health Care Experiments at Many Farms,” 752. For sources on the optimism of medicine after World War II, see James T. Patterson, Grand Expectations: The United States, 1945–1970 (New York: Oxford University Press, 1996); Allan M. Brandt and Martha Gardner, “The Golden Age of Medicine?” in Medicine in the Twentieth Century, ed. Roger Cooter and John Pickstonepp (Amsterdam: Harwood Academic Publishers, 2000), 21–37; Bert Hansen, Picturing Medical Progress from Pasteur to Polio (New Brunswick, NJ: Rutgers University Press, 2009). 73. Hunt, A Colonial Lexicon, 268; S. Ogoh Alubo, “Debt Crisis, Health, and Health Services in Africa,” Social Science Medicine 31, no. 6 (1990): 639–648; Cooper, Africa since 1940, 107–109. For infant mortality rates in the United States, see http://www.infoplease.com/ipa/A0779935.html. 74. Michael Worboys, “The Spread of Western Medicine,” in Western Medicine, ed. Irvine Loudon (Oxford: Oxford University Press, 1997), 255. 75. Richard Gray, Black Christians and White Missionaries (New Haven, CT: Yale University Press, 1990); Mr. Ogunsheye, “Higher Education Opportunities in English and French Speaking Africa,” Report of the Seminar, African Woman Designs Her Future, MMM. 76. Csordas, ed., Transnational Transcendence; Frances Raday, “Culture, Religion, and Gender,” International Journal of Constitutional Law 1, no. 4 (2003): 663–715; Valuer, “The Roman Catholic Church.”

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77. Joan F. Burke, These Catholic Sisters Are All Mamas! (Leiden: E. J. Brill, 2001); James Kroeger, “Papal Mission Wisdom: Five Mission Encyclicals 1919–1959,” in A Century of Catholic Mission, ed. Bevans, 93–100. 78. Fidei Donum, 1957. http://www.vatican.va/holy_father/pius_xii/encyclicals/ documents/hf_p-xii_enc_21041957_fidei-donum_en.html. 79. Ritamarie Bradley, “A Survey of a Decade Past,” Sister Formation Bulletin 10, no. 4 (1964): 32–36; Marjorie Noterman Beane, From Framework to Freedom (Lanham, MD: University Press of America, 1993); Kenneth Briggs, Double Crossed: Uncovering the Catholic Church’s Betrayal of American Nuns (New York: Doubleday, 2006). 80. Marie Augusta Neal, From Nuns to Sisters: An Expanding Vocation (Mystic, CT: Twenty Third Publications, 1990); Briggs, Double Crossed. 81. Margaret O’Hogartaigh, Quiet Revolutionaries: Irish Women in Education, Medicine and Sport, 1861–1964 (Dublin: History Press Ireland, 2011); Dries, The Missionary Movement, 247. 82. Mary Duff, Gerard Fealy, Isabelle Smyth, eds., Nursing Education in Drogheda, 1946–2004 (Drogheda: Nursing Education Commemorative Committee, 2004); Sister Margaret Mary Nolan, Medical Missionaries of Mary: Covering the First Twenty-Five Years of the Medical Missionaries of Mary, 1937–1962 (Dublin: Medical Missionaries of Mary, 1962); The Medical Missionaries of Mary in Drogheda, 1939–1999 (Drogheda: Old Drogheda Society, 1999), MMM; O’Hogartaigh, Quiet Revolutionaries. 83. This is similar to Protestant missionaries. See Rosemary Gagan, A Sensitive Independence: Canadian Methodist Women Missionaries in Canada and the Orient, 1881– 1925 (Toronto: McGill-Queens University Press, 1992); Sonya Grypma, Healing Henan: Canadian Nurses at the North China Mission, 1888–1947 (Vancouver: University of British Columbia Press, 2008); and Grypma, China Interrupted: Japanese Internment and the Reshaping of a Canadian Missionary Community (Waterloo, ON: Wilfrid Laurier University Press, 2012). For more on Catholics, see Carmen M. Mangion, Contested Identities: Catholic Women Religious in Nineteenth Century England and Wales (Manchester: Manchester University Press, 2008). 84. Leon Joseph Cardinal Suenens, The Nun in the World (London: Burns and Oates, 1962); Briggs, Double Crossed. 85. Kroeger, “Papal Mission”; and Stephen B. Bevans, “Mission at the Second Vatican Council: 1962–1965,” in A Century of Catholic Mission, ed. Bevans, 101–111. 86. Charles Morrison, American Catholic: The Saints and Sinners Who Built America’s Most Powerful Church (New York: Vintage Books, 1997); Garry Wills, Head and Heart: A History of Christianity in America (New York: Penguin Books, 2007). 87. Bevans, “Mission at the Second Vatican Council.” 88. Hastings, A History of African Christianity, 1950–1975, 168. 89. Philip Gleason, Keeping the Faith: American Catholicism Past and Present (Notre Dame, IN: University of Notre Dame Press, 1987), 84.

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90. Maureen Sullivan, The Road to Vatican II: Key Changes in Theology (New York: Paulist Press, 2007); Byrnes, Reverse Mission. 91. Ellen Leonard, “The Process of Transformation: Women Religious and the Study of Theology, 1955–1980,” in Changing Habits: Women’s Religious Orders in Canada, ed. Elizabeth M. Smyth (Ottawa, Canada: Novalis, 2007), 230–246. 92. Gaudium et Spes, December 7, 1965. http://www.vatican.va/archive/hist_ councils/ii_vatican_council/documents/vat-ii_cons_19651207_gaudium-etspes_en.html. 93. Dignitatis Humanae, December 7, 1965. http://www.vatican.va/archive/hist_ councils/ii_vatican_council/documents/vat-ii_decl_19651207_dignitatishumanae_en.html. 94. Bevans, “Mission at the Second Vatican Council”; and Ad Gentes, December 7, 1965.

http://www.vatican.va/archive/hist_councils/ii_vatican_council/

documents/vat-ii_decree_19651207_ad-gentes_en.html. 95. Perfectae Caritatis, October 28, 1965. http://www.vatican.va/archive/hist_coun cils/ii_vatican_council/documents/vat-ii_decree_19651028_perfectae-caritatis_ en.html. 96. Smith, “Catholic Women in Mission, 1910–2010.” 97. Robert, American Women in Mission; Leonard, “The Process of Transformation.” 98. Louise O’Reilly, The Impact of Vatican II on Women Religious: Case Study of the Union of Irish Presentation Sisters (Newcastle upon Tyne: Cambridge Scholars, 2013), 33. 99. Lumen Gentium, November 21, 1964. http://www.vatican.va/archive/hist_ councils/ii_vatican_council/documents/vat-ii_const_19641121_lumengentium_en.html. See also Adrian Hastings, ed., Modern Catholicism: Vatican II and After (New York: Oxford University Press, 1991). 100. Leonard, “The Process of Transformation”; Barbra Mann Wall, American Catholic Hospitals: A Century of Changing Markets and Missions (New Brunswick, NJ: Rutgers University Press, 2011). 101. Populorum Progressio, March 26, 1967. http://www.vatican.va/holy_father/paul_ vi/encyclicals/documents/hf_pvi_enc_26031967populorum_en.html. Pope John died after the Council’s first session, and Pope Paul VI succeeded him and finished the Council. 102. http://www.afrikaworld.net/afrel/atrxadocs.htm. 103. Evangelii Nuntiandi, 1975. http://www.rcan.org/evangelization/Evan_Nunt_PPVI. pdf. See also Jeffrey Gros, “A Century of Hope and Transformation: Mission and Unity in Catholic Perspective,” in A Century of Catholic Missions, ed. Bevans, 162–171. 104. Anglican-Roman Catholic International Commission, “The Final Report,” Windsor, September 1981. Copy located at Oxford Centre for Mission Studies, Oxford, UK. 105. Amy L. Koehlinger, The New Nuns: Racial Justice and Religious Reform in the 1960s (Cambridge, MA: Harvard University Press, 2007); Barbra Mann Wall, “Catholic Sister Nurses in Selma, Alabama, 1940–1972,” Advances in Nursing Science 32,

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no. 1 (January–March 2009): 91–102; Barbra Mann Wall, “Catholic Nursing Sisters and Brothers and Racial Justice in Mid-20th-Century America, Advances in Nursing Science 32, no. 2 (2009): E81. 106. Sister M. Charles Borromeo, ed., The New Nuns (New York: New American Library, 1967), 46. 107. “Final Communiqué: Pan African Conference of Third World Theologians, December 17–23, 1977, Accra, Ghana,” in African Theology en Route, ed. Kofi Appiah-Kubi and Segio Torres (Maryknoll, NY: Orbis Books, 1977). Quotations are on p. 194. See also Emmanuel Martey, African Theology: Inculturation and Liberation (Maryknoll, NY: Orbis Books, 1993); Ngindu Mushete, “The History of Theology in Africa: From Polemics to Critical Irenics,” in African Theology en Route, ed. Appiah-Kubi and Torres, 23–35; Stephen I. Munga, “Beyond the Controversy: A Study of African Theologies of Inculturation and Liberation” (PhD diss., Swedish Evangelical Mission, Uppsala, Sweden, 1998); Benezet Bujo, African Theology in Its Social Context (Maryknoll, NY: Orbis Books, 1992), 70–71; Gwinyai H. Muzorewa, “African Liberation Theology,” November 1989, http:// www.disa.ukzn.ac.za/webpages/DC/BtNov89.1015.2296.003.002.Nov1989.8/ BtNov89.1015.2296.003.002.Nov1989.8.pdf. 108. Kwesi A. Dickson, Uncompleted Mission: Christianity and Exclusivism (Maryknoll, NY: Orbis Books, 1991). Quotations are on pp. 122–123. 109. Dermot Keogh, “Church and State,” in Modern Catholicism: Vatican II and After, ed. Adrian Hastings (London: SPCK, 1991), 300; Dries, The Missionary Movement. 110. Catholic Medical Mission Board, The Medical Mission News 1, no. 1 (July 1931); Official Catholic Directory (New York: P. J. Kenedy and Sons, 1935). 111. David Hardiman, “The Mission Hospital,” in From Western Medicine to Global Medicine, ed. Harrison, Jones, and, Sweet. 112. Hastings, A History of African Christianity, 1950–1975; and Hastings, African Catholicism. 113. Robert, Christian Mission; and Robert, Gospel Bearers. 114. More, Fee, and Parry, eds., Women Physicians and the Cultures of Medicine; Regina Morantz-Sanchez, Sympathy and Science: Women Physicians in American Medicine (Chapel Hill: University of North Carolina Press, 1985, 2000); Steven J. Peitzman, A New and Untried Course: Woman’s Medical College and Medical College of Pennsylvania, 1850–1998 (New Brunswick, NJ: Rutgers University Press, 2000); Wall, Unlikely Entrepreneurs; and O’Hogartaigh, Quiet Revolutionaries. 115. Sheryl Nestel, “(Ad)ministering Angels: Colonial Nursing and the Extension of Empire in Africa,” Journal of Medical Humanities 19, no. 4 (1998): 257–277. 116. Rosemary Fitzgerald, “Rescue and Redemption—The Rise of Female Medical Missions in Colonial India during the Late Nineteenth and Early Twentieth Centuries,” in Nursing History and the Politics of Welfare, ed. Anne Marie Rafferty, Jane Robinson, and Ruth Elkan (New York: Routledge, 1997), 64–79; Sweet and Digby, “Race, Identity, and the Nursing Profession.”

NOTES TO PAGES 23–24

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117. Hastings, African Catholicism, 41–50; oral histories with three MMM by author, August 18, 2011; Drogheda, Ireland. 118. Nancy Rose Hunt, “Placing African Women’s History and Locating Gender,” Social History 14, no. 3 (October 1989): 359–379; Luise White, The Comforts of Home: Prostitution in Colonial Nairobi (Chicago: University of Chicago Press, 1990); Catherine Coles and Beverly Mack, eds., Hausa Women in the Twentieth Century (Madison: University of Wisconsin Press, 1991); Philomena Muiruri, Women Street Vendors in Nairobi, Kenya: A Situational and Policy Analysis Within a Human Rights Framework (Addis Ababa, Ethiopia: Organization for Social Science Research in Eastern and Southern Africa, 2010); Jennifer Okumu Wengi, Weeding the Millet Field: Women’s Law and Grassroots Justice in Uganda (Nairobi: Law Africa Publishing (K), 2011). 119. Helen Sweet, “Expectations, Encounters and Ecclesiastics: Mission Medicine in Zululand, South Africa,” in From Western Medicine to Global Medicine, ed. Harrison, Jones, and Sweet, 330–360; Jane Turrittin, “Colonial Midwives and Modernizing Childbirth in French West Africa,” in Women in African Colonial Histories, ed. Jean Allman, Susan Geiger, and Nakanyike Musisi (Bloomington: Indiana University Press, 2002), 71–91; Alex McKay, “Towards a History of Medical Missions,” Medical History 51, no. 4 (October 2007): 547–551; Elizabeth Isichei, “Does Christianity Empower Women? The Case of the Anaguta of Central Nigeria,” in Women and Missions: Past and Present, Anthropological and Historical Perspectives, ed. Fiona Bowie, Deborah Kirkwood, and Shirley Ardener (Oxford: Berg Publishers, 1993), 209–228. 120. Interview with Sister Mary Nesta, IHM, by Lauren Johnson and author, August 30, 2012, Minneapolis, MN. 121. Quoted in D. Ugwu-Oju, What Will My Mother Say? (Chicago: Bonus Books, 1995), 127. 122. Okwu, Igbo Culture; Kupalo, “African Sisters’ Congregations”; and Burke, These Catholic Sisters Are All Mamas. 123. Mohamed Adhikari, ed., Burdened by Race: Coloured Identities in Southern Africa (Cape Town, South Africa: University of Cape Town Press, 2009), xx. 124. Press Release, “First Catholic Hospital in Gold Coast,” Folder 15.1, Africa = HFH— Berekum, Ghana, Medical Mission Sisters Archives, Fox Chase, Pennsylvania (hereafter cited as MMS-F); and Holy Family Hospital Berekum, 1948–1988, 40th Anniversary Brochure, MMS-F. 125. Vaughan, Curing Their Ills; Valuer, “The Roman Catholic Church.” 126. Nicholas Ibeawuchi Omenka, The School in the Service of Evangelization (Leiden: E. J. Brill, 1989); Bujo, African Theology in Its Social Context; Paolo Suess, “The Constitutive Nature of Justice, Peace and Liberation for Mission,” in A Century of Catholic Mission, ed. Bevans, 196–205. 127. Ajayi, Christian Missions in Nigeria; Nicholas Omenka, “The Role of the Catholic Mission in the Development of Vernacular Literature in Eastern Nigeria,” Journal of Religion in Africa 16, fasc. 2 (June 1986): 121–137; Good, The Steamer Parish.

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128. Omenka, The School in the Service of Evangelization, 92. 129. Bonk, The Routledge Encyclopedia; Steven Feierman, “Healing as Social Criticism in the Time of Colonial Conquest,” African Studies 54, no. 1 (1995): 73–88. 130. The Encyclopedia of Christianity (Grand Rapids, MI: Eerdman’s/Brill, 2003). Some sisters obtained their education in medicine before they joined convents. 131. Official Catholic Directory (New York: P. J. Kenedy and Sons, 1945). 132. Robert, American Women in Mission; Claudette LaVerdiere, On the Threshold of the Future: The Life and Spirituality of Mother Mary Joseph Rogers, Founder of the Maryknoll Sisters (Maryknoll, NY: Orbis Books, 2011). 133. Dengel, Mission for Samaritans; Dries, The Missionary Movement; oral history with Sister Jane Gates by Lauren Johnson and author, March 17, 2012; Biographical Sketch by Pauline Willis 195, RG 1–01–1.3, MMS-F; Anne Z. Cockerham and Arlene W. Keeling, “Finance and Faith at the Catholic Maternity Institute, Santa Fe, New Mexico, 1944–1969,” Nursing History Review, 18 (2010): 151–166; Medical Mission Sisters, http://www.medicalmissionsisters.org/2013/02/14/50-years-ofhealing-presence-in-uganda/. 134. Medical Missionaries of Mary, Medical Missionaries of Mary (Dublin: Three Candles, 1962). 135. Nolan, Medical Missionaries of Mary; Ralph Schram, A History of the Nigerian Health Services (Ibadan: Ibadan University Press, 1971), 411. 136. Missionary Sisters of Our Lady of the Holy Rosary, Silver Sheaves: A Record of Twenty-five Years at Home and in Africa (Killeshandra, Ireland: Missionary Sisters of Our Lady of the Holy Rosary, 1949), located at the Bodleian Library, Oxford, UK. See also Okwu, Igbo Culture; and http://mshr.org/index.php?page= health-care. 137. Okwu, Igbo Culture. Sister Joseph Therese Agbasiere appears in figure 4.1. 138. Ibid.; Ezeh, Archbishop Charles Heerey. 139. Reverend Celestine A. Obi, A Hundred Years of the Catholic Church in Eastern Nigeria, 1885–1985 (Onitsha, Nigeria: Africana-Fep Publishers, 1985); Golden Jubilee, Congregation of the Sisters of the Immaculate Heart of Mary, Mother of Christ, Nigeria, Commemorative Brochure, 1937–1987. 140. Jay P. Dolan, In Search of an American Catholicism (New York: Oxford University Press, 2002); Bonk, The Routledge Encyclopedia. 141. Patricia Byrne, “A Tumultuous Decade, 1960–1970,” in Transforming Parish Ministry: The Changing Roles of Catholic Clergy, Laity, and Women Religious, ed. Jay P. Dolan, R. Scott Appleby, Patricia Byrne, and Debra Campbell (New York: Crossroad, 1990), 154–175. 142. Dolan, In Search of an American Catholicism, 234. 143. Bateman, “Ireland’s Spiritual Empire”; Hogan, The Irish Missionary Movement; Mary Peckham Magray, The Transforming Power of the Nuns: Women, Religion, and Cultural Change in Ireland, 1750–1900 (New York: Oxford University Press, 1998). The quotation is on pp. 10–11.

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144. Emmet J. Larkin, The Historical Dimensions of Irish Catholicism (New York: Arno Press, 1976), 2. 145. Ursula Stepsis and Dolores Liptak, eds., Pioneer Healers: The History of Women Religious in American Health Care (New York: Crossroad, 1989), 31–33; Joy Clough, RSM, “Chicago’s Sisters of Mercy,” Chicago History 32, no. 1 (Summer 2003): 42–55. 146. Silver Sheaves, 39; Hogan, The Irish Missionary Movement, 164; Bateman, “Ireland’s Spiritual Empire”; J. Lee, Ireland 1912–1985: Politics and Society (Cambridge: Cambridge University Press, 1989). 147. Hasia Diner, Erin’s Daughters in America: Irish Immigrant Women in the Nineteenth Century (Baltimore, MD: Johns Hopkins University Press, 1983); Magray, The Transforming Power. 148. Dunch, “Beyond Cultural Imperialism”; Kajsa Ekholm Friedman and Jonathan Friedman, Modernities, Class, and the Contradictions of Globalization: The Anthropology of Global Systems (Lanham, MD: Alta Mira Press, 2008). 149. Michael Marten, “On Knowing, Knowing Well and Knowing Differently: Historicising Scottish Missions in 19th and Early 20th Century Palestine,” in Transnational and Historical Perspectives, ed. Fleischmann, Grypma, Marten, and Okkenhaug, 238. CHAPTER 2

NURSING, MEDICINE, AND MISSION IN GHANA

1. Statement by the Gold Coast Government on the Report of the Commission of Enquiry into the Health Needs of the Gold Coast (Accra, Gold Coast: Government Printer, 1955). 2. Kwame Nkrumah, “Broadcast to the Nation,” December 24, 1957. http://www .panafricanperspective.com/nkrumahquotes.html. 3. Stephen Addae, The Evolution of Modern Medicine in a Developing Country: Ghana 1880—1960 (Edinburgh: Durham Academic Press, 1997), 73–80; Patrick Twumasi, “Colonialism and International Health: A Study in Social Change in Ghana,” Social Science and Medicine 15B (1981): 147–151; Michael Amoah, Nationalism, Globalization, and Africa (New York: Palgrave Macmillan, 2011); Sodsi Sodsi-Tettey, “Kwame Nkrumah’s Revolutionary Health Platform,” September 29, 2001. See http://www.ghanaweb.com/GhanaHomePage/features/artikel .php?ID=169401. 4. Justin Willis examines similar questions of Protestant mission hierarchies in “The Nature of a Mission Community: The Universities’ Mission to Central Africa in Bonde,” in Missionary Encounters: Sources and Issues, ed. Robert A. Bickers and Rosemary Seton (Surrey, UK: Curzon, 1996), 128–152. See also Lauren Johnson and Barbra Mann Wall, “Women, Religion, and Maternal Health Care in Ghana, 1945–2000, Family and Community Health 37, no. 3 (2014): 223–230. 5. 40th Anniversary Brochure, Holy Family Hospital Berekum, 1948–1988, MMS-F. 6. Government of Ghana, Official Portal, http://www.ghana.gov.gh/index.php/ about-ghana/regions/brong-ahafo. 7. Addae, The Evolution of Modern Medicine. Quotation is on p. 20.

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8. Ibid; Patrick A. Twumasi, “A Social History of the Ghanaian Pluralistic Medical System,” Social Science and Medicine 13 B (1979): 349–356; Christine Böhmig, Ghanaian Nurses at a Crossroads (Leiden: African Studies Center, 2010); S. N. Otoo, “A Pattern of Training for the Nursing Service in Ghana,” Ghana Medical Journal 7 (1968): 79–86; Jonathan Roberts, “Remembering Korle Bu Hospital: Biomedical Heritage and Colonial Nostalgia and the Golden Jubilee Souvenir,” History in Africa 38 (2011), 193–226. 9. Addae, The Evolution of Modern Medicine. 10. Statement by the Gold Coast Government; Addae, The Evolution of Modern Medicine. 11. Addae, The Evolution of Modern Medicine, 89–90. 12. Ibid.; “Kwame Nkrumah’s Revolutionary Health Reform,” posted September 29, 2009 at http://www.ghanaweb.com/GhanaHomePage/NewsArchive/artikel .php?ID=169401. 13. 40th Anniversary Brochure. 14. Quoted ibid., 10. 15. Mother Anna Dengel to Most Rev. H. Paulissen, April 28, 1950; and Berekumhene [Chief] letter to Rev. Mother, October 24, 1950, Berekum, Ghana, Box 2, folder 13, Archives of the Medical Mission Sisters, Acton, UK (hereafter cited as MMS-UK). 16. 40th Anniversary Brochure. 17. Ibid., and Letter to Mother, Berekum, May 6, 1953, Ghana Box, MMS-F. 18. Letter to Mother Dengel, December 7, 1952, Ghana Box, MMS-F. 19. Ibid. 20. Bishop Bronk to Sister Camillus, October 12, 1957; and Bronk to Sister Camillus, October 23, 1957, Ghana Box, MMS-F. 21. Mother Dengel to Your Excellency, September 10, 1957, Ghana Box, MMS-F. 22. Ibid. 23. Bishop of Kumasi to Reverend Dear Mother, September 29, 1957, Africa—Region of Ghana Ecclesiastic Correspondence, MMS-F. 24. Bishop Bronk to Rev. Mother, February 24, 1958, Africa—Region of Ghana Ecclesiastic Correspondence, MMS-F. 25. Oral history with Sister Jane Gates by Lauren Johnson and author, March 17, 2012; Fox Chase, Pennsylvania. 26. Ibid. 27. Ibid. 28. Ibid. 29. 40th Anniversary Brochure; and Gates oral history. 30. Barbra Mann Wall, American Catholic Hospitals: A Century of Changing Markets and Missions (New Brunswick, NJ: Rutgers University Press, 2011).

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31. Berekum Chronicle, January 11, 1953, Medical Mission Sisters, Holy Family Hospital, Berekum, Ghana (hereafter cited as MMS-G). 32. Letter to Sister M. Camillus, May 28, 1963, MMS-F. 33. Barbra Mann Wall, Unlikely Entrepreneurs: Catholic Sisters and the Hospital Marketplace, 1865–1925 (Columbus: Ohio State University Press, 2005); Richard P. McBrien, Harper Collins Encyclopedia of Catholicism (San Francisco: HarperCollins Publishers, 1995): 414; James, M. O’Toole, ed., Habits of Devotion: Catholic Religious Practice in Twentieth-Century America (Ithaca, NY: Cornell University Press, 2004). 34. Semi-Annual Letter to Superior General from Holy Family Hospital, May 1961, Ghana Box, MMS-F. 35. Letter to Sister M. Camillus, November 29, 1961; and Semi-Annual Letter to the Superior General, November 1961, Ghana Box, MMS-F. 36. Mother M. Benedict to Rev. Mother Dengel and the General Council, March 14, 1963; and Excerpt from Mother Benedict’s letter, April, 12, 1963, from Venezuela, Berekum Box 2, folder 21, MMS-UK. 37. Ibid. Helen Sweet notes similarities in South African mission hospitals. See Helen Sweet, “Mission Nursing in the South African Context: The Spread of Knowledge During the Colonial and Apartheid Periods,” in Transnational and Historical Perspectives on Global Health, Welfare and Humanitarianism, ed. Ellen Fleischmann, Sonya Grypma, Michael Marten, and Inger Marie Okkenhaug (Kristiansand, Norway: Portal Forlag Publishers, 2013), 137–155. 38. Letter to Mother Benedict, July 28, 1964, Ghana folder, MMS-F. See also Standing Orders, Holy Family Hospital, Berekum Box 2, folder 21, MMS-UK. 39. Otoo, “A Pattern of Training.” 40. Ibid; Addae, The Evolution of Modern Medicine; Bohmig, Ghanaian Nurses; Mary Opare and Judy E. Mill, “The Evolution of Nursing Education in a Post Independence Context—Ghana from 1957 to 1970,” Western Journal of Nursing Research 22, no. 8 (2000): 936–944; I. Ewusi-Mensah, “Post-Colonial Psychiatric Care in Ghana,” The Psychiatrist 25 (2001): 228–229. See also http://kbth.gov.gh/index.php?id=126. 41. Böhmig, Ghanaian Nurses, 230. 42. Ibid.; and Berekum Chronicle, January 26, 1953. 43. Otoo, “A Pattern of Training”; Berekum Chronicle, May 15, 1953; December 10, 1953. 44. Berekum Chronicle, January 11, 1954. 45. Sister Marianne to Sister M. Pauline, April 22, 1954, Berekum Box 1, MMS-UK. 46. Berekum Chronicle, March 5 and April 22, 1954. 47. Ibid., December 13 and December 20, 1954. 48. Ibid, April 22 and 23, 1955. 49. Roland Oliver and Anthony Atmore, Africa Since 1800 (Cambridge: Cambridge University Press, 2006). 50. Berekum Chronicle, January 31, 1955.

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51. Sister M. Patricia to Mother Dengel, December 11, 1955, MMS-UK. 52. Berekum Chronicle, January 28 and April 6, 1956, MMS. Quotation is from April 28, 1956. 53. Ibid., July 3, 1956. 54. Ibid.. Quotation is from July 20, 1956. See also August 4, 1956. 55. Ibid., October 1, 1956. 56. Ibid., October 3 and 4, 1956. 57. Addae, The Evolution of Modern Medicine, 251. 58. Helen Sweet and Anne Digby, “Race, Identity, and the Nursing Profession in South Africa,” in New Directions in the History of Nursing, ed. Barbara Mortimer and Susan McGann (London: Routledge, 2005), 109–124; Shula Marks, “‘We were men nursing men’: Male Nursing on the Mines in Twentieth-Century South Africa,” in Deep HiStories: Gender and Colonialism in Southern Africa, ed. Wendy Woodward, Patricia Hayes, and Gary Minkley (New York: Rodopi, 2002), 177–205. 59. Berekum Chronicle, October 25 and 31, 1956. 60. Oral history with Sister Alice Hanks by author and Lauren Johnson, February 22, 2012; Fox Chase, Pennsylvania; oral history with Sister Catherine Shean by Lauren Johnson and Madeline Reckart, July 6, 2012; Fox Chase, Pennsylvania. 61. Berekum Chronicle, February 1, 1957. 62. Ibid., various entries for 1957, 1958, and 1959. See also Sister M. Paula to Mother Dengel, January 4, 1960, MMS-UK. 63. Hanks and Shean oral histories; 40th Anniversary Brochure. See also Sister Cephas Hanks letter to Mother Dengel, January 4, 1963, MMS-UK; and http:// rgnmtc.webs.com/aboutus.htm. 64. Holy Family Hospital School of Nursing Policies, Berekum, 1963. Ghana folder, MMS-UK. 65. Numerous copies of “Why I want to be a nurse,” 1964, Ghana folder, MMS-F. 66. 40th Anniversary Brochure. 67. Sister M. Aloysius to Mother Miriam, August 9, 1966, MMS-F. 68. Holy Family Hospital Berekum, “Works for the First Three Quarters of 1965,” MMS-F; and Holy Family Hospital Berekum Programme, 1966, Berekum, Ghana, Box 2, folder 15, MMS-UK. 69. Florence Nightingale Pledge, http://nursingworld.org/FunctionalMenuCategories/ AboutANA/WhereWeComeFrom/FlorenceNightingalePledge.aspx. 70. Wall, Unlikely Entrepreneurs. 71. Director of Medical Services to Sister Administrator, Holy Family Hospital, March 13, 1967; Sister Marie Therese to Rev. J. Essuah, July 10, 1967; Africa—HFHBerekum, Ghana, Misereor Application, MMS-F. 72. Letter to Mother Dengel, June 7, 1963, MMS-F.

NOTES TO PAGES 54–60

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73. “Industrial Relations under the CPP Government,” Trade Unions and Industrial Relations in Ghana (Rosa Luxumberg Foundation, 2011), 5. http://www.ghanatuc .org/Labour-Relations-Manual.pdf. 74. Holy Family Hospital Semi-Annual Letter to Superior General, May 1961, MMS-F. 75. American Pro-province Medical Works, Africa, Berekum, Ghana; and Fox Chase, PA, MMS-F and MMS-G. 76. Gates oral history. 77. Summary of Discussions with Mother Benedict, Week of February 1, 1964, MMS-F. 78. Addae, The Evolution of Modern Medicine. 79. Copy of Hospitals Division, Ministry of Health, Special Aid Programme for Mission Hospitals, June 24, 1961; and memo dated September 26, 1961; MMS-F. 80. Sister Jane Gates to Mother Benedict, October 16, 1962, MMS-F. 81. Address by Mr. Osei Owusu-Afriyie, Minister of Health, at the Christian Medical Workers Conference, September 25, 1965. Berekum, Ghana, Box 2, folder 19, MMS-UK. 82. Minutes of the Meeting of the National Medical Advisory Board (National Catholic Secretariat), Accra, December 15, 1965, MMS-F. The National Catholic Secretariat is the Executive Arm of the Bishops Conference and was established in 1960. 83. Report on Meeting of National Medical Advisory Board, Accra, April 23, 1966, MMS-F. 84. National Catholic Secretariat Department of Health, “Report on Meeting of Catholic Hospitals, Held at Accra 30th September 1966, Ghana Folder, MMS-F. “Mohammedans” followed the teachings of the Islamic prophet Muhammad. 85. 40th Anniversary Brochure. 86. Maxwell Owusu, “Rebellion, Revolution, and Tradition: Reinterpreting Coups in Ghana,” Comparative Studies in Society and History 31, no. 2 (April 1989): 372–397. 87. Summary of Discussions with Mother Benedict, February 1, 1964, MMS-F. 88. Ibid.; 40th Anniversary Brochure; Addae, The Evolution of Modern Medicine; Opare and Mill, “The Evolution of Nursing Education.” 89. Addae, The Evolution of Modern Medicine, 89–92. 90. Admission Records, 1961, 1965, 1970, 1974, Holy Family Hospital, Berekum, Ghana, MMS-G. 91. Admission Records, 1965, Holy Family Hospital, Berekum, Ghana, MMS-G; and Nancy Rose Hunt, A Colonial Lexicon of Birth Ritual, Medicalization, and Mobility in the Congo (Durham, NC: Duke University Press, 1999), 268. 92. “Ghana: Official Policy Statement,” Studies in Family Planning 44, no. 1 (1969): 1–7. Quotation is on p. 1.

NOTES TO PAGES 61–65

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93. Ibid. 94. http://www.vatican.va/holy_father/paul_vi/encyclicals/documents/hf_p-vi_ enc_25071968_humanae-vitae_en.html. 95. E-mail communication by author with Sister Ursula Preusser, MMS-G, January 31, 2012. 96. Admission Records, 1974, Holy Family Hospital, Berekum, Ghana, MMS-G. 97. Gates oral history, and oral history with Sister Rose Kershbaumer by author and Lauren Johnson, May 10, 2012; Fox Chase, Pennsylvania. 98. Godelieve Prové, Becoming Human: A Story of Transformation through Conflict and Healing (Delft, the Netherlands: Aburon Academic Publishers, 2004); “National Council for Higher Education,” New Ghana 7, no. 24 (August 28, 1963); Dance Concert brochure, Institute of African Studies, April 7, 1965; and Popular Reports of the Medical Mission Sisters, 1974, MMS-F. 99. Quoted in Prové, Becoming Human, 112. 100. Common Purpose, 1973, MMS-F. 101. Report of Central Assembly, 1974. Quoted in Prové, Becoming Human, 147. 102. 40th Anniversary Brochure. 103. Prové, Becoming Human. CHAPTER 3

SHIFTING MISSION IN RURAL TANZANIA

1. Luis Gomes Sambo, “Health Systems and Primary Health Care in the African Region,” African Health Monitor #14, March 2012. http://www.aho.afro.who.int/ en/ahm/issue/14/editorial/health-systems-and-primary-health-care-africanregion. 2. Angelyn Dries, The Missionary Movement in American Catholic History (Maryknoll, NY: Orbis Books, 1998), 257. 3. The use of the terms “clinic” and “dispensary” often overlapped. 4. Michael Jennings, “Missions and Maternal and Child Health Care in Colonial Tanganyika, 1919–1939,” in Medical Missionaries in India and Africa, ed. David Hardiman (London: Clio Medica Press, 2007), 227–250; Terence O. Ranger, “Godly Medicine: The Ambiguities of Medical Mission in Southeastern Tanzania, 1900–1945,” Social Science and Medicine 15, no. 3 (1981): 261–277. 5. Michael Jennings, “‘A Matter of Vital Importance’: The Place of the Medical Mission in Maternal and Child Healthcare in Tanganyika, 1919–39,” Clio Medica (Amsterdam: International Academy of the History of Medicine, 2006), 228. Others have discussed the pluralization of the medical system. See for example, David Hardiman, “The Mission Hospital, 1880–1960,” in From Western Medicine to Global Medicine: The Hospital beyond the West, ed. Mark Harrison, Margaret Jones, and Helen Sweet (Hyderabad, India: Orient Blackswan, 2009), 198–220; and Helen Sweet, “Expectations, Encounters and Ecclesiastics: Mission Medicine in Zululand, South Africa,” in From Western Medicine to Global Medicine, ed. Harrison, Jones, and Sweet, 330–359.

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6. Jennings, “A Matter of Vital importance”; and Shula Marks, Divided Sisterhood: Race, Class, and Gender in the South African Nursing Profession (New York: St. Martin’s Press, 1994). 7. Jan P. Van Bergen, Development and Religion in Tanzania: Sociological Soundings on Christian Population in Rural Transformation (Madras: Christian Literature Society, 1981). 8. Ibid. 9. Jean-Paul Wiest, Maryknoll in China: A History, 1918–1955 (Armonk, NY: M. E. Sharpe, 1997). 10. Richard M. Titmuss, Brian Abel-Smith, George Macdonald, Arthur W. Williams, and Christopher H. Wood, The Health Services of Tanganyika: A Report to the Government (London: Pitman Medical Publishing, 1964). For an analysis of the different medical practitioners in Tanzania, see John Iliff, East African Doctors (Cambridge: Cambridge University Press, 1998). 11. Legislative Council of Tanganyika, A Review of the Medical Policy of Tanganyika, Dar es Salaam, 1949. Noted in Titmuss et al., The Health Services of Tanganyika. 12. Wiest, Maryknoll in China. 13. Sister Margaret Rose Winkelmann, M.M., “Maryknoll’s History in Africa,” http://www.maryknollafrica.org/History.htm. 14. Ibid. 15. Ibid. For an analysis of hospitals in Southeast Tanzania, see Walter Bruchhausen, “Medicine between Religious Worlds: The Mission Hospitals of South-East Tanzania during the Twentieth Century,” in From Western Medicine to Global Medicine, ed. Harrison, Jones, and Sweet, 172–197. 16. Nancy Rose Hunt, A Colonial Lexicon of Birth Ritual, Medicalization, and Mobility in the Congo (Durham, NC: Duke University Press, 1999), 239. For a more global view see Valerie Fildes, Lara Marks, and Hilary Marland, eds., Women and Children First: International Maternal and Infant Welfare, 1870–1945 (London: Routledge, 1992). 17. See http://kmtshiratihospital.org/. 18. Catholic Mission, Kowak, Maryknoll Sisters Archives, Ossining, NY (hereafter cited as MSA). 19. Steven Feierman, “Struggles for Control: The Social Roots of Health and Healing in Modern Africa,” African Studies Review 28, no. 2/3 (1985): 73–147. 20. Catholic Mission, Kowak, MSA. 21. http://www.maryknollafrica.org/History11.htm. 22. The nearest medical school for training was Uganda’s Makerere College. See Titmuss et al., The Health Services of Tanganyika. 23. Catholic Mission, Kowak, MSA. 24. Ranger, “Godly Medicine.”

NOTES TO PAGES 71–76

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25. Catholic Mission, Kowak, MSA. 26. Peter LeJacq, “History: Maryknoll and Health,” http://www.maryknollafrica.org/ History11.htm. See also Kowak Mission Dispensary, 1950, MSA. Father Peter LeJacq was a physician to Africa in the mid-1980s and 1990s. Africa History, Box 4, MSA. 27. Diary Digest, October 18, 1949; Diaries, Africa, Mauritius, and Tanganyika, Box 1, MSA. 28. Diary Digest., February 20, 1952, Box 1, MSA. 29. Diary Digest, September 27, 1949, Box 1, MSA. 30. Barbra Mann Wall, Unlikely Entrepreneurs: Catholic Sisters and the Hospital Marketplace, 1865–1925 (Columbus: Ohio University Press, 2005). 31. Diary Digest, December 22, 1951, Box 1, MSA. 32. Ibid., May 4, 1952. 33. Ibid., December 20, 1951. 34. Ibid., January 13, 1952. 35. Ibid., August 23, 1952; June 17, 1953; June 30, 1953. 36. Father Edward M. Baskerville, http://maryknollmissionarchives.org/index .php/history/246-baskervillefredwardm. See also Maryknoll Sisters Diary, Kowak, Africa, November 10, 1956, Diaries Africa, Mauritius and Tanganyika, Box 2, MSA. 37. United Nations Trusteeship Council, “Report of the United Nations Visiting Mission to Trust Territories in East Africa, 1954, on Tanganyika,” p. 123, Africa History, Box 2, MSA. 38. Hunt, A Colonial Lexicon, 250. 39. Report on Kowak Mission Dispensary, 1950, Africa History Box 4, MSA. 40. See Sister Marian Jan Puszcz, “New Dispensary Opened,” The Parish Monthly (n.d.), pp. 25, 29, MSA. The sisters estimated that mortality rate was 70 percent, but that could not be validated, Africa History, Box 4, MSA. 41. Diary Digest, April 7, 1957, Diaries Africa, Mauritius and Tanganyika, Box 2; and Maryknoll Sisters’ Diary, Kowak Africa, November 1959–September 1960, MSA. 42. Maryknoll Sisters Diary, Kowak, Africa, October 1960–June 1961, Diaries Africa, Mauritius and Tanganyika, Box 2, MSA. 43. Kowak Catholic Hospital, “Smith Kline & French Fellowship Report,” 1961, MMA. 44. Ann Digby and Helen Sweet, “Nurses as Culture Brokers in Twentieth Century South Africa,” in Plural Medicine, Tradition and Modernity, 1800–2000, ed. W. Ernst (London: Routledge, 2002), 113–129. See also Juanita De Barros, “‘A Laudable Experiment’: Infant Welfare Work and Medical Intermediaries in Early Twentieth Century Barbados,” in Public Health in the British Empire: Intermediaries, Subordinates, and the Practice of Public Health, 1850–1960, ed. Ryan Johnson and Amna Khalid (New York: Routledge, 2012), 100–117.

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45. Markku Hokkanen, Medicine and Scottish Missionaries in the Northern Malawi Region, 1875–1930: Quests for Health in a Colonial Society (Lewiston, NY: Edwin Mellen Press, 2007); Charles M. Good, The Steamer Parish: The Rise and Fall of Missionary Medicine on an African Frontier (Chicago: University of Chicago Press, 2004). 46. N.S.K. Tumbo et al., Labour in Tanzania (Dar es Salaam: Tanzania Publishing House, 1978). 47. Titmuss et al., The Health Services of Tanganyika. 48. Medical Care at Kowak Hospital, 1961, Kowak, Tanzania; and Kowak Catholic Hospital, “Smith Kline & French Fellowship Report, 1961, Part II, The Tanganyika Territory,” Africa History, Box 4, MSA. 49. Geertje Boschma, “The Meaning of Holism in Nursing: Historical Shifts in Holistic Nursing Ideas,” Public Health Nursing 11, no. 5 (1994): 324–330; Karen Buhler-Wilkerson, False Dawn: The Rise and Decline of Public Health Nursing, 1900–1930 (New York: Garland, 1989). 50. Maryknoll Sisters Diary, Kowak, Africa, October 1960–June 1961, Diaries Africa, Mauritius and Tanganyika, Box 2, MSA. See also Sister James Elizabeth Reese, “Madonna Plan—National Council of Catholic Women, The Village Nurse—We Need Her for Maternity Welfare in Tanganyika,” May 1964, Africa History, Box 1, MSA. 51. Reese, “Madonna Plan.” 52. Titmuss, et al., The Health Services of Tanganyika, 195. 53. “Africa’s Medical Work,” March 1969, Africa History, Box 2, MSA. 54. Reese, “Madonna Plan.” 55. Ibid. 56. Theodore Brown, Marcus Cueto, and Elizabeth Fee, “The World Health Organization and the Transition from International to Global Health,” American Journal of Public Health 96, no. 1 (2006): 62–72. 57. Sister Marian Teresa, “Tanzania,” 1967, Africa History, Box 2, MSA; Chester Gillis, Roman Catholicism in America (New York: Columbia University Press, 1999). The sisters did not record Regina’s last name. 58. “Birth of Tanzania, Africa,” 1966. For quotation, see Sister Marian Teresa, “Tanzania,” 1967, Africa History, Box 2, MSA. 59. Letter to the Sister at Kowak Hospital from Area Commissioner, North Mara, January 14, 1965, Africa History, Box 2, MSA. 60. Letter to W. Chambili, Area Commissioner, from Sister Marian Jan, January 19, 1965, ibid. 61. Ibid. 62. Ibid. 63. Letter to Sister Margaret Rose from Sister Marian Jan, January 20, 1965, ibid. 64. Ibid.

NOTES TO PAGES 82–86

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65. Letter to W. Chambili from Bishop John Rudin, January 22, 1965, ibid. 66. Steven Feireman, “Explanation and Uncertainty in the Medical World of Ghaambo,” Bulletin of the History of Medicine 74, no. 2 (2000): 317–344. 67. Letter to John Rudin from Regional Commissioner, February 19, 1965, in Africa History, Box 2, MSA. 68. Sister Marian Jan to Sister Margaret Rose, March 10, 1965, ibid. 69. Dr. E. A. Schroeder to Bishop Rudin, March 20, 1965, ibid. 70. Diary Digest, November 1964–November 1965, Diaries Africa, Mauritius and Tanganyika, Box 2, MSA. 71. http://maryknollmissionarchives.org/index.php/history/1294-obriensrmargaret. 72. http://www.ihsistersofafrica.org/home/who-we-are. 73. “The Catholic Church in Tanzania,” AMECA Doc. Service, May 29, 1984, MSA. 74. Michael Amoah, Nationalism, Globalization, and Africa (New York: Palgrave Macmillan, 2011); Neville Linton, “Nyerere’s Road to Socialism,” Canadian Journal of African Studies 2, no. 1 (1968): 1–6; Peter G. Forster, “Religion and the State in Tanzania and Malawi,” Journal of Asian and African Studies 32 (1997): 163–184. 75. Sister Miriam Rachel Kunkler to President Julius K. Nyerere, June 24, 1970. Africa History, Box 3, MSA. 76. Ibid. 77. Brown, Cueto, and Fee, “The World Health Organization.” 78. Firoze Manji and Carl O’Coill, “The Missionary Position: NGOs and Development in Africa,” International Affairs 78, no. 3 (2002): 572; Ruth Compton Brouwer, “When Missions Became Development: Ironies of ‘NGOization’ in Mainstream Canadian Churches in the 1960s,” in Protestant Mission and Local Encounters in the Nineteenth and Twentieth Centuries: Unto the Ends of the World, ed. H. Hielssen, K. H. Skeie, and I. M. Okkenhaug (Leiden: Brill, 2011), 259–291. 79. Dries, The Missionary Movement, 211. 80. Ibid.; Gillis, Roman Catholicism in America, 216; Frederick Cooper and Randall Packard, eds., International Development and the Social Sciences (Berkeley: University of California Press, 1997); Ruth Compton Brouwer, “Canadian Protestant Overseas Missions to the Mid-Twentieth Century: American Influences, Interwar Changes, Long-Term Legacies,” in Empires of Religion, ed. Hilary M. Carey (New York: Palgrave Macmillan, 2008), 288–310. 81. J. K. Nyerere, “The Church and Society,” in Nyerere, Freedom and Development (Oxford: Oxford University Press, 1973); Mary Ryan Hotchkiss, “Saints, Icons, and Role Models,” Not So Far Afield: A Newsletter of The Maryknoll Affiliates, 22, no. 5 (2013): 1; Dave Hough, “Teacher Gives Maryknoll Lesson,” Citizen Register (Ossining, NY), October 22, 1970; Frieder Ludwig, Church and State in Tanzania: Aspects of a Changing in Relationship, 1961–1994 (Leiden: Brill, 1999). 82. To President Julius K. Nyerere from Sister Miriam Rachel Kunkler, MSA.

NOTES TO PAGES 86–89

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83. Ibid.; Penny Lernoux, Hearts on Fire: The Story of the Maryknoll Sisters (Maryknoll, NY: Orbis Books, 1993); and Dana Robert, American Women in Mission: A Social History of their Thought and Practice (Macon, GA: Mercer University Press, 1997), 399–401. Dominican Father Gustavo Gutierrez coined the phrase “preferential option for the poor.” He was one of the original founders of liberation theology in Latin America. 84. Timothy A. Byrnes, Reverse Mission: Transnational Religious Communities and the Making of US Foreign Policy (Washington, DC: Georgetown University Press, 2011), 79. 85. Alfred T. Hennelly, ed., Liberation Theology: A Documentary History (Maryknoll, NY: Orbis Books, 1990); Susan Fitzpatrick-Behrens, The Maryknoll Catholic Mission in Peru, 1943–1989 (Notre Dame, IN: University of Notre Dame Press, 2012). 86. Adrian Hastings, ed., Modern Catholicism: Vatican II and After (New York: Oxford University Press, 1991). Quotation is on p. 222. 87. Quoted in Suzanne DeChillo, “Maryknoll Pursues Its Vision of Mission,” New York Times, March 31, 1985. See also Lernoux, Hearts on Fire, 254. 88. John L. Allen Jr., “Liberation Theology African Style,” National Catholic Reporter, March 27, 2009. http://ncronline.org/all-things-catholic/liberation-theologyafrican-style. I also am grateful to my friend Dr. James T. Carroll, professor of history at Iona College, for helping me to understand the differences between the Latin American and African contexts. 89. Ludwig, Church and State in Tanzania. 90. Quoted in Lernoux, Hearts on Fire, 215. 91. “Sister Marian Teresa’s Work,” Bega Kwa Bega, no. 2 and 4 ( July–August 1979). Newsletters, Africa World Section, MSA. 92. Lernoux, Hearts on Fire, 216; Van Bergen, Development and Religion in Tanzania. 93. Jean Pruitt, “Regional Rustlings,” Africa Region, no. 5 (December 5, 1970), Newsletters Africa World Section, MSA. 94. Cicely D. Williams, B.M. Oxon, and D.T.M. and H. Lond, “Kwashiorkor,” The Lancet 226, no. 5855 (1935): 51–52. 95. Pruitt, “Regional Rustlings.” 96. Es’kia Mphahlele, Down Second Avenue: Growing Up in a South African Ghetto (London: Faber and Faber, 1959, 1971). For quotation, see Jane Vella, “Regional Rustlings,” Africa Region, no. 1 (January 31, 1971), 1. 97. “Regional Rustlings,” Africa Region, no. 3 (March 31, 1971): 1, 3. 98. Kenneth Briggs, Double Crossed: Uncovering the Catholic Church’s Betrayal of American Nuns (New York: Doubleday: 2006). 99. Paolo Friere, Pedagogy of the Oppressed (New York: Continuum Press, 1970). 100. Helder Camara, Church and Colonialism: The Betrayal of the Third World (Franklin, WI: Sheed and Ward, 1969). 101. For quotation, see “Regional Rustlings,” Africa Region, no. 7 (July 31, 1971): 1.

NOTES TO PAGES 89–94

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102. “Regional Rustlings,” Africa Region, no. 7 (July 31, 1971), 5. 103. http://www.sacbc.org.za/about-us/departments/justice-and-peace/. 104. Lernoux, Hearts on Fire; and Byrnes, Reverse Mission. 105. Anselm Odhiambo Anacleti, “Changes in Tanzanian Society in Past Thirty Years,” Assembly 7/30–8/2/1978, MSA. 106. Ibid. For a similar situation in Cameroon, see Fiona Bowie, “The Elusive Christian Family: Missionary Attempts of Define Women’s Roles. Case Studies from Cameroon,” in Women and Missions: Past and Present, Anthropological and Historical Perspectives, by Fiona Bowie, Deborah Kirkwood, and Shirley Ardener (Providence, RI; Oxford: Berg, 1993), 145–164. 107. Van Bergen, Development and Religion in Tanzania. 108. http://www.maryknollafrica.org/History11.htm. See also Maryknoll Sisters Presence in Kungombe since 1980, Africa History, Box 1, MSA. CHAPTER 4 CATHOLIC MEDICAL MISSIONS AND TRANSNATIONAL ENGAGEMENT IN NIGERIA

1. Paul Gifford, African Christianity: Its Public Role (Bloomington: Indiana University Press, 1998), 65. 2. Robert Wuthnow and Stephen Offutt, “Transnational Religious Connections,” Sociology of Religion 69, no. 2 (2008): 209–232. 3. An older source is Ade Ajayi, Christian Missions in Nigeria 1841–1891: The Making of a New Elite (London: Longmans, Green, 1965). For newer scholarship, see Toyin Falola and Matthew M. Heaton, A History of Nigeria (New York: Cambridge University Press, 2010); and Olukunle Ojeleye, The Politics of Post-War Demobilisation and Reintegration in Nigeria (Surry, UK: Ashgate, 2010). For quotation, see Falola and Heaton, A History of Nigeria, 92. 4. Ralph Schram, A History of the Nigerian Health Services (Ibadan: Ibadan University Press, 1971). 5. Ndubisi Obiaga, The Politics of Humanitarian Organizations Intervention (Lanham, MD: University Press of America, 2004); and Richard Burgess, Nigeria’s Christian Revolution: The Civil War Revival and its Pentecostal Progeny (1967–2006) (Oxford: Regnum Books International, 2008). 6. F. K. Ekechi, Missionary Enterprise and Rivalry in Igboland, 1857–1914 (London: Frank Cass, 1972). 7. E. A. Ayandele, The Missionary Impact on Modern Nigeria (New York: Humanities Press, 1966), 115. 8. Ibid., and Falola and Heaton, A History of Nigeria. 9. Obiaga, The Politics; Laurie S. Wiseberg, “Christian Churches and the Nigerian Civil War,” Journal of African Studies 2 (1972): 297–331; Augustine S. O. Okwu, Igbo Culture and the Christian Missions, 1857–1957 (New York: University Press of America, 2010); Ajayi, Christian Missions in Nigeria.

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10. Augustine S. O. Okwu, “The Beginning of the Maynooth Movement in Southern Nigeria and the Rise of the St. Patrick’s Missionary Society, 1920–1930,” Journal of Religion in Africa 10, fasc. 1 (1979): 22; Ajayi, Christian Missions in Nigeria. 11. Wiseberg, “Christian Churches”; Ayandele, The Missionary Impact; Nicholas Ibeawuchi Omenka, The School in the Service of Evangelization (Leiden: E.J. Brill, 1989); and Okwu, Igbo Culture. 12. Quoted in E. C. Amucheazi, Church and Politics in Eastern Nigeria, 1945–66: A Study in Pressure Group Politics (Lagos: Macmillan Nigeria, 1986), 15. See also Burgess, Nigerian’s Christian Revolution; and Roy Samuel Doron, “Forging a Nation while Losing a Country: Igbo Nationalism, Ethnicity, and Propaganda in the Nigerian Civil War 1968–1970” (Ph.D. diss., University of Texas at Austin, 2011). http://repositories.lib.utexas.edu/bitstream/handle/2152/ETD-UT-2011– 08–3715/DORON-DISSERTATION.pdf?sequence=1. 13. Andrew G. Onokerhoraye, Social Services in Nigeria: An Introduction (London: Kegan Paul International, 1984). See also Schram, A History of the Nigerian Health Services; Bethabile Lovely Dolamo and Simeon Keyada Olubiyi, “Nursing Education in Africa: South Africa, Nigeria, and Ethiopia Experiences,” International Journal of Nursing and Midwifery 5, no. 2 (2013): 14–21. 14. “Visitation. The Film Story of the Medical Missionaries of Mary,” MMMA. 15. Missionary Sisters of Our Lady of the Holy Rosary, Silver Sheaves: A Record of Twenty-five Years at Home and in Africa (Killeshandra, Ireland: Missionary Sisters of Our Lady of the Holy Rosary, 1949), 71. 16. Ibid., 76. 17. Onokerhoraye, Social Services in Nigeria; Schram, A History of the Nigerian Health Services; Ajayi, Christian Missions in Nigeria; and Joseph McGlade, The Missions: Africa & the Orient (Dublin: Gill and Son, 1967). 18. Sir Sydney Phillipson, Grants in Aid of the Medical and Health Services provided by Voluntary Agencies in Nigeria (Lagos: Government Printer, 1949). 19. Mary Bull, “The Medical Services of Nigeria in 1954–5: A Survey Prepared for the Medicine and Public Health in Africa Section,” Oxford Development Records Project, Wellcome Unit, Oxford, UK; Minutes of the Meeting of the Sub-committee Appointed by the Eighth Meeting of the Eastern Regional Medical Advisory Board, January 13, 1956, 1/Fou/4 (e) 272, MMMA. 20. Advisory Board, St. Luke’s Hospital, Anua, October 14, 1952, 1/Fou/4(e)87, MMMA. 21. Letters from African/Anua, March 13, 1953, 1/Fou/4(e)217, MMMA. 22. Minutes of the Meeting of the Sub-committee. 23. Amucheazi, Church and Politics; Hakeem Onapajo, “Politics for God: Religion, Politics and Conflict in Democratic Nigeria,” Journal of Pan African Studies 4, no. 9 (January 2012). http://readperiodicals.com/201201/2600144731.html. 24. Schram, A History of the Nigerian Health Services; Mary-Noelle Ethel Ezeh, Archbishop Charles Heerey and the History of the Church in Nigeria, 1890–1967

NOTES TO PAGES 96–99

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(Mumbai: St. Pauls, 2005); Fiona Bateman, “Ireland’s Spiritual Empire: Territory and Landscape in Irish Catholic Missionary Discourse,” in Empires of Religion, ed. Hilary M. Carey (New York: Palgrave Macmillan, 2008), 267–287. The first quotation is on page 267. The second quotation is noted on p. 17 in Hilary M. Carey, “Introduction: Empires of Religion,” in Empires of Religion. 25. Bateman, “Ireland’s Spiritual Empire,” 268. 26. Quoted in Okwu, Igbo Culture, 232. 27. Missionary Sisters of Our Lady of the Holy Rosary, Silver Sheaves; and Schram, A History of the Nigerian Health Services. 28. Numerous Medical Missionaries of Mary archival publications, MMMA. Excerpts of this section are published in Barbra Mann Wall, “Beyond the Imperial Narrative: Catholic Missionary Nursing, Medicine and Knowledge Translation in Sub-Saharan Africa, 1945–1980,” in E. Fleischmann, S. Grypma, M. Marten, and I. M. Okkenhaug, eds., Transnational and Historical Perspectives on Global Health, Welfare and Humanitarianism, pp. 90–109 (Kristiansand, Norway: Portal Forlag, 2013). Used with permission. 29. Rosemary Cullen Owens, A Social History of Women in Ireland, 1870–1970 (Dublin: Gill and Macmillan, 2005). 30. Medical Missionaries of Mary, 21st Anniversary, 1958. Quotation is on p. 39. See also 1940 Constitution, Chapter XVI, Article 171; and “MMM Missionary Expansion,” 1937–1962, MMMA. 31. Hospital Statistics, Annual Returns, 1955, folder 10, 1/Fou/10/3/(i), MMMA. 32. Ibid., 1960, Folder 15, 1/Fou/10/3/(m), MMMA. 33. Ibid. 34. Sister Margaret Mary Nolan, Medical Missionaries of Mary: Covering the First Twenty-Five Years of the Medical Missionaries of Mary, 1937–1962 (Dublin: Medical Missionaries of Mary, 1962), 23, MMMA. 35. Medical Missionaries of Mary, Medical Missionaries of Mary, 1937–1962 (Dublin: Three Candles, 1962). 36. Schram, A History of the Nigerian Health Services; Prof. Olaniyan, “Memorandum on Questionnaire Received on 24th June, 1966,” MMMA. 37. Bull, “The Medical Services of Nigeria.” 38. Diana Solano and Anne Marie Rafferty, “Can Lessons Be Learned from History? The Origins of the British Imperial Nurse Labour Market: A Discussion Paper,” International Journal of Nursing Studies 44 (2007): 1055–1063. 39. Syllabus for Preliminary Nurses’ Training School, Nigeria, 1951, MMMA. See also Pauline Scanlan, The Irish Nurse: A Study of Nursing in Ireland; History and Education, 1718–1981 (Nure, Manorhamilton, Co. Leitrim, Ireland: Drumlin Publications, 1991); and Solano and Rafferty, “Can Lessons be Learned from History?” 40. B. N. Fawkes, Inspector of Training Schools, to Nigeria papers, DT 18/723, UK National Archives, Kew, UK; and Report of St. Luke’s Hospital, 1961, MMM; Bull,

NOTES TO PAGES 99–103

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“The Medical Services of Nigeria”; M. O. Fletcher, “Inspection Notes of St. Luke’s Hospital Anua,” December 6, 1959, 1/Fou/4 (e) 217; The General Nursing Council for England and Wales, For Registration Committee, January 9, 1958, 1/Fou/4(e), 277; MMMA. 41. Schram, A History of the Nigerian Health Services. 42. Working Party on Medical Services in Republic of Nigeria, St. Luke’s Hospital, Anua, July 18, 1966;” Report of St. Luke’s Hospital, 1968, n.p., MMMA. 43. List of Foundations Made since the Beginning of the Congregation, MMM; Nolan, Medical Missionaries of Mary; Medical Services in Republic of Nigeria, St. Luke’s Hospital, July 18, 1966; Olaniyan, Memorandum; Schram, A History of the Nigerian Health Services. 44. “What Has Been Done,” MMM Missionary Expansion, 1937–1962, MMM. 45. Burgess, Nigeria’s Christian Revolution; Amucheazi, Church and Politics. There were exceptions. See, for example, “Adventist Nurse in Biafra,” Australasian Record 74, no. 9 (March 2, 1970). 46. Wiseberg, “Christian Churches”; John J. Stremlau, The International Politics of the Nigerian Civil War, 1967–1970 (Princeton, NJ: Princeton University Press, 1977), 118. 47. Wiseberg, “Christian Churches.” 48. “Dail Eireann—25th June, 1968, Adjournment Debate, Nigeria-Biafra Hostilities,” DFA/EMB Lagos P 13/3/B, National Archives of Ireland, Dublin (hereafter cited as NAI). 49. Burgess, Nigeria’s Christian Revolution; Stremlau, The International Politics. 50. “Extracts from Second Commonwealth Medical Conference—Kampala 1968— Relating to Nigeria,” MMM. 51. Letter from Rory O’Brien, “Afikpo 1967–1970,” May 20, 1986, to Sister Vincent Ryan, II Biafran War/3, MMM; Schram, A History of the Nigerian Health Services, 226. 52. Sister Pauline Dean, Biafra War Diary, Urua Akpan 1968 (hereafter cited as Diary). 53. St. Mary’s Hospital Report, 1962–1968, MMMA. 54. Ibid. 55. Diary, April 3, 1968. 56. Father Kilbride, “Genocide, 1969,” Catholic Missionary Reports, Clearing House for Nigeria/Biafra Information Records, 1968–1970, DG 168, Box 2, Swarthmore University, Swarthmore, PA (hereafter cited as Clearing House). 57. Diary, April 24, 26, 27, 1968. 58. Ibid., April 29, 1968. For a description of kwashiorkor, see Cicely D. Williams, B. M. Oxon, and D.T.M. and H. Lond, “Kwashiorkor,” The Lancet 226, no. 5855 (1935): 51–52.

NOTES TO PAGES 103–109

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59. Letters to “Mother” dated April 1969, MMMA. 60. Sister Pauline’s diary makes several notations of this. 61. Diary, May 9, 1968. 62. Ibid., May 17, 19, 21, 22 and June 1, 2, 1968. 63. Ibid., May 22, 1968. 64. Ibid., June 10, 1968. 65. Ibid., June 26, 27, 1968. 66. Ibid., June 10, 1968. 67. Ann Digby and Helen Sweet, “Nurses as Culture Brokers in Twentieth Century South Africa,” in Plural Medicine, Tradition and Modernity, 1800–2000, ed. W. Ernst (London: Routledge, 2002), 113–129. 68. Diary, June 28, 1969. 69. “Sister Chris Gill,” and “Sister Joan Cosgrove,” in Irene Christina Lynch, Beyond Faith and Adventure: Irish Missionaries in Nigeria Tell Their Extraordinary Story (Greystones, Wicklow, Ireland: Ross Print Services, 2006). Quotation is on p. 257. 70. Letter to Sisters from Holy Rosary Convent, Emekuku, Owerri, January 19, 1968, Catholic Missionary Reports, DG 168, Box 2, Clearing House. 71. “Nun Is Killed in Biafra Air Raid,” Gettysburg Times, September 19, 1969; and typed letter dated September 15, 1969, in Clearing House documents. See also http://archive.catholicherald.co.uk/article/17th-october-1969/2/nun-killed-innigerian-jet-attack. 72. Diary, June 17, 1968. 73. “Night Flight to Uli,” Radharc (RTE) Archives, aired February 5, 1969. http:// www.rte.ie/archives/exhibitions/1378-radharc/355631-night-flight-to-uli/. 74. “The Church and the War,” Irish Times, March 19, 1968. 75. Michael Mok, “Through Flak-peppered Sky: A Frail Link of Guns and Food,” Life (August 23, 1968), 53. 76. Ken Waters, “Influencing the Message: The Role of Catholic Missionaries in Media Coverage of the Nigerian Civil War,” Catholic Historical Review 90, no. 4 (October 2004): 697–718. 77. Radharc is a group of documentaries broadcast by RTÉ between 1962 and 1996. See “Night Flight to Uli.” http://www.rte.ie/archives/exhibitions/1378-radharc/. RTÉ.ie is the website of Raidió Teilifís Éireann, Ireland’s National Public Service Broadcaster. Used with permission. 78. Ibid. 79. “Bringing Services to the People,” Holy Rosary Sisters, Emekuku, Owerri, at Amaimo, Ikeduru, September–Mid-November, 1968, Catholic Missionary Reports, DG 168, Box 2, Clearing House.

NOTES TO PAGES 109–113

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80. Ibid. 81. “Night Flight to Uli.” 82. Our Lady of Lourdes Hospital, Ihiala, Kwashiorkor Unit, Catholic Missionary Reports, DG 168, Box 2, Clearing House. 83. “Night Flight to Uli”; and Ajayi, Christian Missions in Nigeria. 84. John Manton also makes this point about the MMM documents. See “Global and Local Contexts: The Northern Ogoja Leprosy Scheme, Nigeria, 1945–1960,” Historia, Ciencias, Saude-Manguinbos 10, supplement 1 (2003): 211. 85. Paul J. Yancho, “Catholic Humanitarian Aid and the Nigeria-Biafra Civil War,” in Religion, History, and Politics in Nigeria: Essays in Honor of Ogbu U. Kalu, ed. Chima J. Korieh and G. Ugo Nwokeji (Lanham, MD: University Press of America, 2005), 158–171; Stremlau, The International Politics; Ojeleye, The Politics of PostWar Demobilization; Falola and Heaton, A History of Nigeria. 86. Waters, “Influencing the Message”; and typed copy of statement by Father S. Broderick, February 1968, Catholic Missionary Reports, DG 168, Box 2, Clearing House. 87. Obiaga, The Politics; Father Kilbride, “Genocide, 1969,” Clearing House; Eno Blankson Ikpe, “Migration, Starvation, and Humanitarian Intervention during the Nigerian Civil War,” Lagos Historical Review 1 (2001): 84–96. 88. Wiseberg, “Christian Churches”; Stremlau, The International Politics; Obiaga, The Politics; Enda Staunton, “The Case of Biafra: Ireland and the Nigerian Civil War,” Irish Historical Studies 31, no. 124 (1999): 513–535; Yancho, “Catholic Humanitarian Aid”; Ojeleye, The Politics of Post-War Demobilisation. 89. Bishop Whelan Diary, n.d., Catholic Missionary Reports, DG 168, Box 2, Clearing House. 90. “Aiken to Speak on Biafra,” Evening Herald, September 24, 1968; “To All Missions,” DFA/EMB Lagos P 13/3/A, NAI. 91. Stremlau, The International Politics, 119; Wiseberg, “Christian Churches”; Tony Byrne, Airlift to Biafra: Breaching the Blockade (Dublin: Columbia Press, 1997); Walter Partington, “Biafra’s New Anger against Britain,” Daily Express, April 23, 1968, A-1. 92. Onyema Nkwocha, The Republic of Biafra: Once Upon a Time in Nigeria (Bloomington, IN: Author House, 2010), 306; and Michael J. C. Echeruo, Keynote Address: “Biafra, Civil War, and Genocide.” See http://academic.mu.edu/koriehc/ documents/BiafraconferenceABSTRACTS.pdf. 93. “Sister Dr. Leonie McSweeney,” in Lynch, Beyond Faith and Adventure. 94. Letter dated February 13, 1969, in Letters from the Field, DG 168, Box 15, Clearing House. 95. Letter dated March 17, 1969, ibid. 96. As noted in chapter 1, the pope went to Uganda to speak to the Pan African meeting of Roman Catholic bishops.

NOTES TO PAGES 113–117

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97. Staunton, “The Case of Biafra,” 527. 98. Diary, July 1, 1968. 99. Letter to Sisters, January 25, 1970, Catholic Missionary Reports, DG 168, Box 2, Clearing House. 100. http://secularhumanist.blogspot.com/2011/11/nigerias-civil-war-untold-story .html. See also Wiseberg, “Christian Churches”; Paul Keating to Secretary, Department of External Affairs, Dublin, DFA/EMB Lagos P 13/2/4, NAI. 101. For quotation, see Keating to the Secretary. See also “Irish Missionaries at Port Harcourt, Nigeria, January 20, 1970,” DFA/EMB Lagos P 13/2/4, NAI; Morris Davis, ed., Civil Wars and the Politics of International Relief: Africa, South Asia, and the Caribbean (New York: Praeger, 1975), 69; and Obiaga, The Politics. 102. Reports on hospitals, including St. Luke’s Hospital, Anua, Uyo, 1961–1968, MMMA. 103. St. Mary’s Hospital Report, 1968, MMMA. 104. St. Benedict’s Leprosy Settlement, Ogoja, Report, 1962–1968, MMMA. 105. Missionary Sisters of Our Lady of the Holy Rosary, Silver Sheaves, 54. 106. Interviews with Sister Maria Chinweze and Sister Maria Nkiru by author and Lauren Johnson, August 29, 2012; and Sister Mary Nesta, August 30, 2012; Minneapolis, Minnesota. 107. Ezeh, Archbishop Charles Heerey; http://www.ihmmcsisters.org/newsdetail .php?tab=5; and Nesta interview. 108. Golden Jubilee, Congregation of the Sisters of the Immaculate Heart of Mary, Mother of Christ, Nigeria, Commemorative Brochure, 1937–1987. 109. Ibid., 5–6. 110. Letter from Sister Agnes Maria to Mother M. Reparatrice, September 11, 1968, 11/FOU/6(H)/183, MMMA. 111. Report of St. Luke’s Hospital, Anua Uyo, 1968, MMMA. 112. These appointments were made by Dr. J. E. Henshaw, controller of medical services, Ministry of Health. See Henshaw to Rev. Dr. Bryan D. Usanga, 14 October 1968, Ll/FOU/6H/181, MMM. See also Sister M. Veronica Akpan, http://www.medicalmissionariesofmary.com/index.php/obituaries/187-sr-mveronica-tom-akpan. 113. Letter from Sister M. D. to Mother, April 1969, 11/Fou/6(H)/187, MMMA. 114. Ibid., May 4, 1969, 11/FOU/6(H)/188, MMMA. 115. Adrian Hastings, ed., African Catholicism: Essays in Discovery (London: SCM Press: 1989). 116. Reverend Raymond Hickey, Fifty Years of Grace: The Catholic Church in Nigeria: 1960—2010 (Jos, Nigeria: Augustinian Publications, 2010). 117. Reverend Celestine A. Obi, A Hundred Years of the Catholic Church in Eastern Nigeria, 1885–1985 (Onitsha, Nigeria: Africana-Fep Publishers, 1985).

NOTES TO PAGES 117–120

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118. For a similar analysis, see Ian Linden, “The Roman Catholic Church in Social Crisis: The Case of Rwanda,” in Christianity in Independent Africa, ed. Edward Fashole-Luke, Richard Gray, Adrian Hastings, and Godwin Tasie (Bloomington: Indiana University Press, 1978), 242–254. 119. This is similar to Inger Marie Okkenhaug’s account of Protestant missionaries caring for Armenians during the period of genocide after World War I. See Inger Marie Okkenhaug, “Refugees, Relief, and the Restoration of a Nation: Norwegian Mission in the Armenian Republic, 1922–1925,” in Protestant Mission and Local Encounters in the Nineteenth and Twentieth Centuries: Unto the Ends of the World, ed. Hilde Nielssen, Karina Hestad Skeie, I. M. Okkenhaugpp (Leiden/Boston: Brill, 2011), 207–232. For a story of missionary physician Ruth Parmelee’s work in Turkey and Greece after World War I, see Virginia A Metaxas, “Ruth A. Parmelee, Esther P. Lovejoy, and the Discourse of Motherhood in Asia Minor and Greece in the Early Twentieth Century,” in Women Physicians and the Cultures of Medicine, ed. Ellen S. More, Elizabeth Fee, and Manon Parry (Baltimore, MD: Johns Hopkins University Press, 2009), 274–293. 120. Oral histories on August 18, 2011, with three MMM confirm this. See also Waters, “Influencing the Message”; and Ratna Kapur, “The Tragedy of Victimization Rhetoric: Resurrecting the ‘Native’ Subject in International/Post-Colonial Feminist Legal Politics,” Harvard Human Rights Journal 15 (2002): 1–37. 121. Obiaga, The Politics; Amucheazi, Church and Politics; Linden, “The Roman Catholic Church in Social Crisis”; Wiseberg, “Christian Churches”; Adrian Hastings, “The Ministry of the Catholic Church in Africa, 1960–1975,” in Christianity, ed. Fashole-Luke et al., 26–42; and Timothy A. Byrnes, Reverse Mission: Transnational Religious Communities and the Making of US Foreign Policy (Washington, DC: Georgetown University Press, 2011). 122. Elizabeth Isichei, A History of Christianity in Africa: From Antiquity to the Present (Grand Rapids, MI: William B. Eerdmans, 1995), 291; Burgess, Nigeria’s Christian Revolution. 123. Ikpe, “Migration,” 94. 124. Waters, “Influencing the Message”; John Hannigan, Disasters without Borders (Cambridge: Polity, 2012), 56; Joe Humphreys, God’s Entrepreneurs: How Irish Missionaries Tried to Change the World (Dublin: New Island, 2010). 125. Lynch, Beyond Faith and Adventure; Hastings, “The Ministry.” CHAPTER 5

TRANSNATIONAL COLLABORATION IN PRIMARY HEALTH CARE

1. Quotation in Margaret Mary Nolan, Medical Missionaries of Mary, Covering the First Twenty-Five Years of the Medical Missionaries of Mary, 1937–1962 (Dublin: Medical Missionaries of Mary, 1962), 147, MMMA. 2. Oral History with Sister Rose Kershbaumer by Lauren Johnson and author May 10, 2012; Fox Chase, Pennsylvania.

NOTES TO PAGES 121–122

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3. O. Akerele, I. Tabibzadeh, and J. McGilvray, “A New Role for Medical Missionaries in Africa,” WHO Chronicle 30 (1976): 175–180; (no author), “The CMC Story,” Contact, no. 161/162 ( June–July and August–September 1998): 1–56. 4. Alex Quaison-Sackey, “The African Personality,” in Quaison-Sackey, Africa Unbound: Reflections of an African Statesman (New York: Praeger, 1963). Quotation is on p. 53. 5. Ibid., 52. See also Benezet Bujo, African Theology in Its Social Context (Maryknoll, NY: Orbis Books, 1992), 45. 6. Sister Mary Laetitia and Sister M. Francis Patrick, Medicine in the Service of Foreign Missions (Cincinnati, OH: National Center, Catholic Students’ Mission Crusade, USA, 1939), 14. 7. Fiona Bateman, “Ireland’s Spiritual Empire: Territory and Landscape in Irish Catholic Missionary Discourse, in Empires of Religion, ed. Hilary M. Carey (New York and Hampshire, UK: Palgrave Macmillan, 2008), 267–287. 8. Laetitia and Patrick, Medicine, 40. 9. Anna Dengel, Mission for Samaritans (Milwaukee: Bruce Publishing, 1945), 35. 10. Minutes of meeting, National Catholic Secretariate Department of Health, October 3, 1966, Accra, Ghana, MMA. 11. Sisters Francis L. Parsons and Thomas C. Dunleavy, “Renewing Religious Power Structures,” in The New Nuns, ed. Sister M. Charles Borromeo (New York: New American Library, 1967), 133–141. 12. Patrick A. Twumasi, “A Social History of the Ghanaian Pluralistic Medical System,” Social Science and Medicine 13 B (1979): 349–356; Charles Anyinam, “Availability, Accessibility, Acceptability, and Adaptability: Four Attributes of African Ethno-Medicine,” Social Science Medicine 25, no. 7 (1987): 803–811; Steven Feierman and John M. Janzen, eds., The Social Basis of Health and Healing in Africa (Berkeley: University of California Press, 1992). Newer scholarship includes Karen E. Flint, Healing Traditions: African Medicine, Cultural Exchange, and Competition in South Africa, 1820–1948 (Athens: Ohio University Press, 2008); Thokozani Xaba, “Marginalised Medical Practice: The Marginalisation and Transformation of Indigenous Medicines in South Africa,” http://www.ces.uc .pt/emancipa/research/en/ft/triunfo.html. 13. Richard M. Titmuss, Brian Abel-Smith, George Macdonald, Arthur W. Williams, and Christopher H. Wood, The Health Services of Tanganyika: A Report to the Government (London: Pitman Medical Publishing, 1964). Located in the Wellcome Unit Library, Oxford, UK. 14. Stephen Feierman, “Healing as Social Criticism in the Time of Colonial Conquest,” African Studies 54, no. 1 (1995): 73–88. 15. Titmuss, et al., The Health Services of Tanganyika, 5; Steven Feierman, “Struggles for Control: The Social Roots of Health and Healing in Modern Africa,” African Studies Review 28, no. 2/3 (1985): 73–147.

NOTES TO PAGES 123–128

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16. To understand indigenous medical services in Tanzania and the people who provide them, see Ole B. Rekdal, “Cross-cultural Healing in East African Ethnography,” Medical Anthropology Quarterly 13, no. 4 (1999): 458–482; Steven Feierman, “Explanation and Uncertainty in the Medical World of Ghaambo,” Bulletin of the History of Medicine 74, no. 2 (2000): 317–344; M. J. Moshi, “Plants Used to Treat Epilepsy by Tanzanian Traditional Healers, Journal of Ethnopharmacology 97, no. 2 (2005): 327–36. 17. Medical Care at Kowak Hospital, 1961, Kowak, Tanzania, Box 5, MSA. 18. Ibid., 3. 19. Walter Bruchhausen, “Medicine between Religious Worlds: The Mission Hospitals of South-East Tanzania during the Twentieth Century,” in From Western Medicine to Global Medicine: The Hospital beyond the West, ed. Mark Harrison, Margaret Jones, and Helen Sweet (New Delhi: Orient Blackswan Private, 2009), 172–197. 20. Medical Care at Kowak Hospital. 21. Helen Sweet, “Expectations, Encounters, and Ecclesiastics: Mission Medicine in Zululand, South Africa,” in From Western Medicine to Global Medicine, ed. Harrison, Jones, and Sweet, 330–359. 22. “Birth of Tanzania, Africa,” 1966, Africa History, Box 2, MSA. 23. See, for example, Ian Harper, “Mediating Therapeutic Uncertainty: A Mission Hospital in Nepal,” in From Western Medicine to Global Medicine, ed. Harrison, Jones, and Sweet, 303–329. 24. Socrates Litsios, “The Christian Medical Commission and the Development of the World Health Organization’s Primary Health Care Approach,” American Journal of Public Health 94, no. 11 (November 2004): 1884–1893; “The CMC Story”; Paul Gifford, African Christianity: Its Public Role (Bloomington: Indiana University Press, 1998). 25. Oral history with Sister Jane Gates by Lauren Johnson and author, March 17, 2012, Fox Chase, Pennsylvania. 26. WCC/RCC Study Group February 1970, “Common Witness and Proselytism;” and WCC/RCC Joint Working Group meeting, May 25–30, 1970; Microfilm, #40 and #41, MS 517, “Relation with the Roman Catholic Church, World Council of Churches,” WCC-11, Box 4201.4.5/14.3 to 4201.4.7/6.4, and Box 4201.4.7/6.5 to 4201.4.8/8. Obtained via interlibrary loan from the WCC Archives, Geneva. 27. WCC/RCC Joint Working Group meeting, May 25–30, 1970. 28. Monica M. McGinley, ed., Medical Mission Sisters News, 1982. 29. 40th Anniversary Brochure, Holy Family Hospital Berekum, 1948–1988, MMS-F. 30. Popular Reports, 1973–1974, MMS-F. 31. Popular Reports of the Districts, 1975 to 1976, MMS-F. 32. Akerele et al., “A New Role”; Litsios, “The Christian Medical Commission.”

NOTES TO PAGES 128–134

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33. Theodore Brown, Marcus Cueto, and Elizabeth Fee, “The World Health Organization and the Transition from International to Global Health,” American Journal of Public Health 96, no. 1 (2006): 62–72. 34. Ibid., and Litsios, “The Christian Medical Commission.” 35. Brown, Cueto, and Fee, “The World Health Organization,” 67; R. H. Bannerman, “WHO’s Programme in Traditional Medicine,” WHO Chronicle 31 (197): 427–428. 36. WHO, “African Traditional Medicine,” Regional Office for Africa, Technical Report Series, No. 1, Brazzaville, 1976. 37. Medical Mission Sisters Annual Report, 1983–1984, Sector Africa, MMS-F. 38. WHO, “African Traditional Medicine”; WHO, “The Promotion and Development of Traditional Medicine,” Technical Report Series, No. 622, 1978; D. M. Warren, and Mary Ann Tregoning, “Research Report: Indigenous Healers and Primary Health Care in Ghana,” Medical Anthropology Newsletter 11, no. 1 (1979): 11–13. 39. D. M. Warren, G. Steven Bova, Mary Ann Tregoning, and Mark Kliewer, “Ghanaian National Policy toward Indigenous Healers,” Social Science and Medicine 16 (1982): 1873–1881; Twumasi, “A Social History.” 40. Warren et al., “Ghanaian National Policy.” 41. Warren and Tregoning, “Research Report.” 42. Mary Ann Tregoning, “Supportive of the Healing of Others,” MMS-F. 43. Barbara L. K. Pillsbury, “Policy and Evaluation Perspectives on Traditional Health Practitioners in National Health Care Systems,” Social Science and Medicine 16, no. 21 (1982): 1825–1834. 44. J. Scott Dodds, film, Healers of Ghana at http://digital.films.com/play/DREQVB. For more information on the blending of traditional and Christian healing, see Richard Gray, Black Christians and White Missionaries (New Haven, CT: Yale University Press, 1990). 45. Film, Healers of Ghana. 46. Warren et al., “Ghanaian National Policy.” 47. Ibid. 48. Ibid.; film, Healers of Ghana; Pillsbury, “Policy and Evaluation Perspectives.” 49. Warren et al., “Ghanaian National Policy, 1878.” 50. Film, Healers of Ghana. 51. Pillsbury, “Policy and Evaluation Perspectives.” 52. Film, Healers of Ghana. 53. Warren et al., “Ghanaian National Policy,” 1876–1877. 54. Ibid. See also Charles M. Good et al., “The Interface of Dual Systems of Health Care in the Developing World: Toward Health Policy Initiatives in Africa,” Social Science and Medicine 13D (1979): 141–154; Feierman, “Struggles”; Natasha Gray, “Independent Spirits: The Politics of Policing Anti-Witchcraft Movements in

NOTES TO PAGES 134–138

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Colonial Ghana, 1908–1927,” Journal of Religion in Africa 35, Fasc. 2 (2005): 139–158. 55. Warren et al., “Ghanaian National Policy.” 56. (No author), “Training Health Workers, Contact 78 (April 1984); and (no author), “Answering ‘Why’—The Ghanaian Concept of Disease,” Contact 84 (April 1985). 57. Pillsbury, “Policy and Evaluation Perspectives,” 1825. 58. Ibid. 59. Oral history with Sister Margaret Moran by author and Lauren Johnson, February 17, 2013; Fox Chase, Pennsylvania. 60. Ibid. 61. Ibid. 62. Ibid. 63. Gray, Black Christians, 83–84. 64. Warren and Tregoning, “Research Report;” oral history with Sister Mary Ann Tregoning by author, November 11, 2013; Fox Chase, Pennsylvania. 65. “Indigenous Healers,” Medical Mission Sisters News 12, no. 4 (1982): 4. 66. Sheila McGinnis, “Healing Charism: Nursing as Its Firm Foundation,” Intercontinent 1, no. 258 (October 2013): 18–19. 67. Kathryn Geurts, “Childbirth and Pragmatic Midwifery in Rural Ghana,” Medical Anthropology 20, no. 4 (2001): 379–408. 68. Joanna Macrae, Anthony B. Zwi, and Lucy Gilson, “A Triple Burden for Health Sector Reform: ‘Post’-Conflict Rehabilitation in Uganda,” Social Science and Medicine 42, no. 7 (1996): 1095–1108. Quotation is on p. 1097. 69. Ali A. Mazrui, ‘Religious Strangers in Uganda: From Emin Pasha to Amin Dada,’ African Affairs 76, no. 301 ( January 1977), 21–38; “Idi Amin: White House-State Department—NSC—CIA-British Government Files;” http://www.paperlessarchives .com/idi_amin.html. See also Madeline Reckart and Barbra Mann Wall, “Resistance and Religion: Health Care in Uganda, 1971–1979,” Family Community Health 37, no. 3 (2014): 231–238; Michael Amoah, Nationalism, Globalization, and Africa (New York: Palgrave Macmillan, 2011). 70. Interviews with Medical Missionaries of Mary by author, June 25, 2012; Drogheda, Ireland. See also Henry Kyemba, A State of Blood (New York: Ace Books, 1977). 71. M. Louise Pirouet, “Religion in Uganda under Amin,” Journal of Religion in Africa 11, Fasc. 1 (1980): 25. 72. Medical Mission Sisters, http://www.medicalmissionsisters.org/2013/02/14/ 50-years-of-healing-presence-in-uganda/. 73. F. J. Bennett, “A Comparison of Community Health in Uganda with Its Two East African Neighbors in the Period 1970–1979,” in Cole P. Dodge and Paul D. Wiebe, eds., Crisis in Uganda: The Breakdown of Health Services, pp. 43–52 (Oxford, UK: Pergamon Press, 1985).

NOTES TO PAGES 138–144

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74. Speciosa Babikinamu, “Hold Carefully the Sick and the Weak,” Intercontinent 1, no. 258 (October 2013): 26. 75. Ibid. 76. Ibid. 77. Ibid., 27. 78. Cole Dodge, “Health Implications of War in Uganda and Sudan,” Social Science Medicine 31, no. 6 (1990): 691–698. 79. Macrae, Zwi, and Gilson, “A Triple Burden.” 80. Oral history with Sister Joan Marie Doud by author, Lauren Johnson, and Madeline Reckart, June 15, 2012; Fox Chase, Pennsylvania. 81. CAA Protocol No. 57/68, “Phasing Out of Virika Hospital, Fort Portal, Uganda,” September 7, 1968. Uganda Box, East Africa, Virika file, MMS-UK. 82. Annual Report, 1977, “Virika Hospital,” Uganda Box, East Africa, MMS-UK. 83. R. M. de Jong to the Administration of the Medical Mission Sisters, Sister Godelieve Prové, October 25, 1978, Uganda Box, East Africa, MMS-UK. 84. Sister Rose M. Kershbaumer to Sister Godelieve Prové, November 19, 1978, Uganda Box, East Africa, MMS-UK. 85. Sister Godelieve Prové to Dr. R. M. de Jong, November 28, 1978. Uganda Box, East Africa, MMS-UK. 86. Ibid. 87. Doud oral history. See also Sister Rita Syron to Sister Godelieve, March 6, 1979, Uganda Box, East Africa, MMS-UK. 88. Medical Mission Sisters, http://www.medicalmissionsisters.org/2013/02/14/ 50-years-of-healing-presence-in-uganda/. 89. Sam Orochi Orach, Is Religion Relevant in Health Care in Africa in the 21st Century?— The Uganda Experience (Kampala: Uganda Catholic Medical Bureau, 2009), 4. 90. Commonwealth Secretariat, “Report of the Second Commonwealth Medical Conference, Kampala,” 1968. 91. Ibid. See also “Medical Missionary of Mary Services in Developing Countries,” 1968, MMMA. 92. Bennett, “A Comparison.” 93. 1972 Nutrition Report, p. 1, IV/Reg-Ho/3/62,63,64,65, Kitovu, UG, MMMA. 94. Annual Reports, 1972, 1973, MMMA. 95. 1973 Report, 1–3. 96. Ibid. 97. Sister L. Ritchie to Mother M. Phelan, September 18, 1972, III/Fou/32, MMMA. 98. Sister Veronica to Mother, July 25, 1974, III/Fou/32/274, MMMA. 99. http://www.medicalmissionariesofmary.com/index.php/component/content/ article/122–1967–1976/219-the-challenge-of-change.

NOTES TO PAGES 145–151

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100. Memoir, Sisters Josephine Grealy, MMMA. 101. Oral history with Sister Jane Gates by author, December 13, 2012; Fox Chase, Pennsylvania. 102. Salvatorian Mission Warehouse, New Holstein, Wisconsin, list of supplies, July 11, July 15, and August 10, 1983, V/Reg-Area 14/15, MMMA. 103. Sister Sheila to Sister Jude, October 11, 1980, V/Reg-Area 14/1, MMMA. 104. Sister Aileen to Sisters, November 7, 1980, V/Reg/Area 14/1, MMMA. 105. Sister Pauline Dean, Primary Health Care Links, Link #1, January 1981. 106. Sister Pauline Dean, Link #3, March 1981; idem, Link #4, April 1981. 107. Sister Pauline Dean, Link #5, May 1981. This book was Corlien M. Varkevisser, Socialisation in a Changing Society (The Hague: CESO, 1973). 108. Sister Pauline Dean, Link #6, June 1981. 109. Sister Pauline Dean, Link # 16, April 1983. 110. Ibid. 111. Paolo Friere, Pedagogy of the Oppressed (New York: Continuum, 1970). 112. Dean, Primary Health Care Links, Link #26, December 1987. 113. Charles M. Good, The Steamer Parish: The Rise and Fall of Missionary Medicine on an African Frontier (Chicago: University of Chicago Press, 2004). 114. Patrick Twumasi, “Colonialism and International Health: A Study in Social Change in Ghana,” Social Science and Medicine 15B (1981): 147–151. Quotation is on p. 149. See also “Lesson One: Overview of Community Health Nursing in Ghana.” http://wikieducator.org/Lesson_1:_Over_view_of_Community_Health_ Nursing_in_Ghana. 115. Titmuss et al., The Health Services of Tanganyika. 116. Feierman, “Struggles.” 117. “The CMC Story,” 3. 118. Julia A. Walsh and Kenneth S. Warren, “Selective Primary Health Care, an Interim Strategy for Disease Control in Developing Countries,” New England Journal of Medicine 301, no. 18 (1979): 967–974. 119. “The CMC Story.” 120. Feierman, “Struggles.” 121. Sister Magdalene Umoren, “Medicine: A Very Humbling Profession,” in Medical Missionaries of Mary, Healing and Development: Yearbook of the Medical Missionaries of Mary, 2004, p. 31, MMMA. 122. This is similar to studies on South Africa. See Jonathan Roberts, “Remembering Korle Bu Hospital: Biomedical Heritage and Colonial Nostalgia in the Golden Jubilee Souvenir,” History in Africa 38 (2011): 193–226; Anne Digby, “Medicine and Witchcraft in South Africa: Initiatives at Victoria Hospitals, Lovedale,” in From Western Medicine to Global Medicine, ed. Harrison, Jones, and Sweet, 221–248;

NOTES TO PAGES 153–158

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Ann Digby and Helen Sweet, “Nurses as Culture Brokers in Twentieth Century South Africa,” in Plural Medicine, Tradition and Modernity, 1800–2000, ed. W. Ernst (London: Routledge, 2002), 113–129. CHAPTER 6 APPRAISING WOMEN RELIGIOUS AND THEIR MISSION WORK

1. Anna Dengel, Mission for Samaritans (Milwaukee: Bruce Publishing, 1945), 5. 2. Ryan Dunch, “Beyond Cultural Imperialism: Cultural Theory, Christian Missions, and Global Modernity,” History and Theory 41, no. 3 (October 2002): 325. 3. Dana L. Robert, Gospel Bearers, Gender Barriers: Missionary Women in the Twentieth Century (Maryknoll, NY: Orbis Books, 2002); and Angelyn Dries, The Missionary Movement in American Catholic History (Maryknoll, NY: Orbis Books, 1998). 4. Joseph McGlade, The Missions: Africa & the Orient (Dublin: Gill and Son, 1967), 29. 5. These statistics are in Paul Gifford, African Christianity: Its Public Role (Bloomington: Indiana University Press, 1998); and Helen Rose Ebaugh, “The Growth and Decline of Catholic Religious Orders of Women Worldwide: The Impact of Women’s Opportunity Structures,” Journal for the Scientific Study of Religion 32, no. 1 (March 1993): 68–75. Only the Asian continent surpassed Africa in terms of number of sisters.. 6. “The Catholic Church in Tanzania,” May 29, 1984, Box 1, Africa History, MSA. 7. Godelieve Prové, Becoming Human: A Story of Transformation through Conflict and Healing (Delft, the Netherlands: Aburon Academic Publishers, 2004). 8. Jonathan J. Bonk, ed., The Routledge Encyclopedia of Missions and Missionaries (New York: Routledge, 2007). 9. Angelyn Dries, “American Catholic ‘Woman’s Work for Woman’ in the Twentieth Century,” in Gospel Bearers, ed. Robert, 140–142. 10. Robert, Gospel Bearers, 23; Emma Wild-Wood, “Worldwide Shifts in Mission from 1910–2010,” Theology 113, no. 873 (May–June 2010): 163–173. 11. Dries, The Missionary Movement. 12. Robert, Gospel Bearers; Wild-Wood, “Worldwide Shifts.” 13. Richard Gray, Black Christians and White Missionaries (New Haven, CT: Yale University Press, 1990). 14. Dana L. Robert, Christian Mission: How Christianity Became a World Religion (West Sussex, UK: Wiley-Blackwell, 2009), 95. 15. This finding supports Steven Feierman’s conclusions in “Struggles for Control: The Social Roots of Health and Healing in Modern Africa,” African Studies Review 28, no. 2/3 (1985): 73–147. 16. Dries, “American Catholic ‘Woman’s Work for Women,’” 142. 17. Prové, Becoming Human, 238. 18. Sister Majella McCarron, from the Irish Province of the Missionary Sisters of Our Lady of the Apostles, in video, “Are Missionaries Accurately Represented In

NOTES TO PAGES 158–163

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the Media?” June 24, 2011. http://worldandmedia.com/global/are-missionariesaccurately-represented-in-the-media-2406.html. 19. Quoted in Penny Lernoux, Hearts on Fire: The Story of the Maryknoll Sisters (Maryknoll, NY: Orbis Books, 1993), 216. 20. Medical Mission Sisters Annual Report, 1979, MMS-F. 21. Oral history with Sisters Jane Gates and Maryanne Tregoning by author, November 11, 2013, Fox Chase, Pennsylvania; and 40th Anniversary Brochure, Holy Family Hospital Berekum, 1948–1988, MMS-F. 22. 40th Anniversary Brochure. Quotation is on p. 12. 23. Dries, The Missionary Movement. Quotation is on p. 257. 24. Richard J. Reid, A History of Modern Africa, 1800 to the Present (Chichester, West Sussex, UK: Wiley-Blackwell, 2012), 355. 25. Fact Sheets, Africa (London: Catholic Missionary Education Centre, 1988), located at the Oxford Center for Mission Studies, Oxford, UK (hereafter cited as OCMS). See also Danny Dorling and Anna Barford, “Shaping the World to Illustrate Inequalities in Health,” Bulletin of the World Health Organization. http:// www.who.int/bulletin/volumes/85/11/07–044131/en/. 26. Bo Malmberg, “Demography and the Development Potential of Sub-Saharan Africa,” White Paper, Current Africa Issues 38 (Stockholm: The Nordic Africa Institute, 2008). 27. 40th Anniversary Brochure. 28. “Celebrating Two Jubilees in Ghana,” December 15, 2011. http://www.medicalmissionsisters.org/2013/02/15/celebrating-two-jubilees-in-ghana/. 29. Joanna Macrae, Anthony B. Zwi, and Lucy Gilson, “A Triple Burden for Health Sector Reform: ‘Post’-Conflict Rehabilitation in Uganda,” Social Science and Medicine 42, no. 7 (1996): 1095–1108. Quotation is on p. 1100. 30. Medical Mission News, Winter 2010. MMS-F. 31. Paul Gifford, “Some Recent Developments in African Christianity,” African Affairs 93, no. 373 (October 1994): 522. 32. See Lynn Hunt’s discussion of globalization in “Reframing History,” Chronicle of Higher Education, August 11, 2014. http://chronicle.com/article/ReframingHistory/148175/. 33. Healing and Development, Yearbook of the Medical Missionaries of Mary, 2002, MMMA. 34. Phillippe Denis, “A Report on AIDS Orphans Programmes in Uganda and Kenya: Study Tour in Kampala, Masaka and Nairobi,” December 8–17, 1994. Unpublished communication provided by Denis to author. See also http:// mmmworldwide.org/. 35. Oral history with Sister Margaret Moran by author and Lauren Johnson, February 17, 2013, Fox Chase, Pennsylvania; and Medical Mission Sisters, “Justice Concerns,” http://www.medicalmissionsisters.org/justice.htm.

NOTES TO PAGES 163–167

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36. Charles Austin, “Maryknollers Pursue Risky Paths in the Third World,” New York Times, June 21, 1981. http://www.nytimes.com/1981/06/21/weekinreview/maryknollers-pursue-risky-paths-in-the-third-world.html. 37. http://www.maryknollsisters.org/about-us/civil-and-human-rights. 38. Timothy A. Byrnes, Reverse Mission: Transnational Religious Communities and the Making of US Foreign Policy (Washington, DC: Georgetown University Press, 2011). 39. Katrin Langewiesche, “African Roman Catholic Missionary Networks between Africa and Europe,” in African Christian Presence in the West: New Immigrant Congregations and Transnational Networks in North America and Europe, ed. Frieder Ludwig and J. Kwabena Asamoah-Gyadu (Trenton, NJ: Africa World Press, 2011), 289–301. 40. F. Nwaigbo, “The HIV/AIDS Pandemic: A Crucial Task for the Church in Africa,” African Ecclesial Review 46, no. 1 (2004): 2–22. 41. J. Hooper, X. Rice, and O. Bowcott, “Catholic Church Tries to Clear Confusion over Condom Use,” The Guardian, November 23, 2010. http://www.guardian .co.uk. See also Mandy Noonan, “The Catholic Church versus HIV/AIDS in Africa,” Consultancy Africa Intelligence, October 2, 2012. http://www .consultancyafrica.com/index.php?option=com_content&view=article&id= 1135:the-catholic-church-versus-hivaids-in-africa-&catid=61:hiv-aids-discussion-papers&Itemid=268. 42. Fact Sheets, Africa; Ruth Bessinger, Charles Katende, Neeru Gupta, “Multi-Media Campaign Exposure Effects on Knowledge and Use of Condoms for STI and HIV/AIDS Prevention in Uganda,” Evaluation and Program Planning 27 (2004): 397–407. 43. Stuart Brody, “Declining HIV Rates in Uganda: Due to Cleaner Needles, Not Abstinence or Condoms,” International Journal of STD and AIDS 15 ( July 1, 2004): 440–441. 44. Norman Hearst and Sanny Chen, “Condom Promotion for AIDS Prevention in the Developing World: Is It Working?” Studies in Family Planning 35, no. 1 (March 18, 2004): 39–47. 45. Anonymous oral histories. 46. Robert Wuthnow and Stephen Offutt, “Transnational Religious Connections,” Sociology of Religion 69, no. 2 (2008): 209–232. Quotation is on p. 214. 47. Ludwig and Asamoah-Gyadu, African Christian Presence in the West; and http:// www.solwodi.de/791.0.html?&L=1. 48. http://mmmworldwide.org/index.php/component/acymailing/archive/view/ listid-12-acajoomlist9/mailid-208-mmm-enewsletter-march-2014/tmplcomponent. 49. Langewiesche, “African Roman Catholic Missionary Networks,” 289–290. 50. Interview with Sister Mary Nesta by author and Lauren Johnson, August 30, 2012; Minneapolis, Minnesota.

NOTES TO PAGES 167–172

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51. Interview with Sister Maria Chinweze Enujiofor by author and Lauren Johnson, August 29, 2012; Minneapolis, Minnesota. 52. Interview with Sister Maureen Bernardine Onovo by author and Lauren Johnson, August 30, 2012; Minneapolis, Minnesota. 53. Interview with Sister Nkiruka Okafor by author and Lauren Johnson, August 29, 2012; Minneapolis, Minnesota. 54. Telephone interview with Sister Immaculata Uwanuakwa by author, September 4, 2012. 55. Wuthnow and Offutt, “Transnational Religious Connections.” 56. Okafor interview. 57. Ibid., and Mary-Noelle Ethel Ezeh, Archbishop Charles Heresy and the History of the Church in Nigeria, 1890–1967 (Mumbai: St. Pauls, 2005). See also interview with Sister Maria Nkiru by author and Lauren Johnson, August 30, 2012; Minneapolis, Minnesota; and Joan F. Burke, These Catholic Sisters Are All Mamas! (Leiden: Brill, 2001). 58. Nkiru interview. 59. Kenneth Briggs, Double Crossed: Uncovering the Catholic Church’s Betrayal of American Nuns (New York: Doubleday: 2006). 60. Ellen Leonard, “The Process of Transformation: Women Religious and the Study of Theology, 1955–1980,” in Changing Habits: Women’s Religious Orders in Canada, ed. Elizabeth M. Smyth (Ottawa: Novalis, 2007), 230–246. 61. Congregatio Pro Doctrina Fidei, “Doctrinal Assessment of the Leadership Conference of Women Religious.” http://www.usccb.org/upload/Doctrinal_ Assessment_Leadership_Conference_Women_Religious.pdf. 62. http://www.vatican.va/holy_father/francesco/apost_exhortations/documents/ papa-francesco_esortazione-ap_20131124_evangelii-gaudium_en.pdf. In 2015, Pope Francis ended the standoff with the American sisters. NOTE ON SOURCES

1. Meredith McKittrick, “Capricious Tyrants and Persecuted Subjects: Reading between the Lines of Missionary Records in Precolonial Northern Namibia,” in Sources and Methods in African History: Spoken, Written, Unearthed, ed. Toyin Falola and Christian Jennings (Rochester, NY: University of Rochester Press, 2003), 220. 2. J.D.Y. Peel, “Problems and Opportunities in an Anthropologist’s Use of a Missionary Archive,” in Missionary Encounters: Sources and Issues, ed. Robert A. Bickers and Rosemary Seton (Surrey, UK: Curzon, 1996), 70–94. 3. Toyin Falola, “Mission and Colonial Documents,” in Writing African History, ed. John Edward Philips (Rochester, NY: University of Rochester Press, 2005), 266–283. 4. Laetitia and Patrick, Medicine in the Service of Foreign Missions, 21, MMS-F.

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5. Numerous secondary sources from African, European, and American scholars were also used: J. F. Ade Ajayi, Christian Missions in Nigeria, 1841–1891: The Making a New Elite (London: Longmans, Green, 1965); E. A. Ayandele, The Missionary Impact on Modern Nigeria (New York: Humanitics Press, 1966); Adrian Hastings, African Catholicism: Essays in Discovery (London: SCM Press, 1989); A. Adu Boahen, African Perspectives on Colonialism (Baltimore: Johns Hopkins University Press, 1987); Richard Gray, Black Christians and White Missionaries (New Haven, CT: Yale University Press, 1990); D. Engels and Shula Marks, eds., Contesting Colonial Hegemony: State and Society in Africa and India (London: British Academic Press, 1994). 6. Philip Fradkin, The Great Earthquake and Firestorms of 1906: How San Francisco Nearly Destroyed Itself (Berkeley: University of California Press, 2005). 7. McKittrick, “Capricious Tyrants,” 221. 8. “Night Flight to Uli,” filmed by Irish Radharc Television Team, 1968, RET Archives, http://www.rte.ie/archives/exhibitions/1378-radharc/355631-nightflight-to-uli/; J. Scott Dodds, “Healers of Ghana,” http://digital.films.com/play/ DREQVB. 9. “Film as Social and Cultural History,” http://historymatters.gmu.edu/mse/film/ socialhist.html. 10. Alessandro Portelli, The Battle of Valle Giulia: Oral History and the Art of Dialogue (Madison: University of Wisconsin Press, 1997). 11. Oral histories were audio taped and written transcriptions were done and approved by interviewees. Questions were open-ended and addressed issues of recruitment, training, payment for health services, strategies, collaborations, and changes in mission over time. Confidentiality was assured in that only the PI and research assistants had access to archival material and tape recordings. Data has been stored in a locked file cabinet in a secured private faculty office. The tapes will be destroyed after seven years if permission is not obtained to house them in local archives. See David K. Dunaway and Willa K. Baum, Oral History: An Interdisciplinary Anthology (Walnut Creek, CA: AltaMira Press, 1996). 12. David Henige, Oral Historiography (London: Longman, 1982); Jane L. Parpart, “Listening to Women’s Voices: The Retrieval and Construction of African Women’s History,” Journal of Women’s History 4, no. 2 (Fall 1992): 171–179; S. B. Gluck and D. Patai, eds., Women’s Words: The Feminist Practice of Oral History (New York: Routledge, 1991); Bala Achi, “Local History in Post-Independent Africa,” in Writing African History, ed. Philips, 374–380; and Joseph E. Holloway, “ ‘What Africa Has Given America’: African Continuities in the North American Diaspora,” in Writing African History, ed. Philips, 403–438.

INDEX

Page numbers followed by an f indicate figures; those by a t, tables. Abel, Sister Bernadetta, 68 abortion services, as focus of Catholic Church, 170 abstinence, and HIV rates, 165 access to care, in sub-Saharan Africa, 153 Accra, Ghana, nurse training school in, 47 Ackerman, Sister Doctor Lea, 165 acupressure, 137 acupuncture, 137 acute care: during periods of violence, 143–146; top-down planning for, 147 Addae, Stephen, 33, 50 Ad Gentes (encyclical), 122, 154 Adhikari, Mohamed, 24 Afikpo, Nigeria, bombing of MMM hospital in, 101 Africa: and Catholic Church, 87, 90, 161; Christianity in, 1–2, 21, 167; nuns in, 154 Africa, sub-Saharan, 7; Catholic health services in, 160–161; colonial medical services in, 4; contraception in, 165; diseases endemic to, 39; health care in, 4, 24–25; influence of mission work on, 152; investment in public health in, 159; Maryknoll Sisters in, 25–26; Medical Missionaries of Mary in, 26–27; Medical Mission Sisters in, 26; medicine in, 121; Missionary Sisters of Holy Rosary in, 27–28; postcolonial, 18; post–World War II missions in, 153–159; Sisters of Immaculate Heart of Mary in, 28. See also specific countries Africa Concern, 111 African Americans, as missionaries, 14 Africanization: of colonial institutions, 14–15; discussions on, 21. See also decolonization African Methodist Episcopal Church, 14 African nurses, at Kowak dispensary, 78 Africans, rural, medical and nursing care for, 4 Agbasiere, Sister Joseph Therese, 28, 107, 108f Ajaero, Noel Mary, 28 Akpan, Sister Veronica, 27, 116 All Africa Conference of Churches, 89

Alma Ata Conference (1978), 128–129, 130, 159; Alma Ata Declaration, 150 American Catholic Church, world missions of, 12. See also Catholic Church Amin, Idi, 137–138, 140, 142, 144; Tanzania invaded by, 144–145 amoebic dysentery, 71 Anacleti, Anselm Odhiambo, 90 ancestor cults, 121 Anderson, Warwick, 10 anemia, 109 Anglican Church Missionary Society, in Nigeria, 93 Angola, Medical Missionaries of Mary in, 11, 162 Anna, Mother (MMS founder), 2, 3, 13, 14, 26, 35, 37–38, 122, 152, 153 antibiotics, 71, 80, 145 antislavery movement, British, 93 Anyogu, Sister Maria, 28, 96 appreciation, feelings of, 158 Armenian massacre, 9 arms race, 125 ascariasis, at Kowak dispensary, 77 Asia, sisters from, 165, 167 Asomugha, Catherine, 28 Association of Women Religious Superiors of Tanzania, 154 auxiliary personnel, training, 160 avitaminosis, 109 Awgu, Nigeria, hospital at, 115 Awusu, Chief Nana Yiadom Boakye, 33, 35 Ayandele, E. A., 9 Babikinamu, Sister Speciosa, 138–140 Bannabikira Sisters, 12 Bannerman, Dr. Robert, 133 Bantu, 71 Banyatereza Sisters, 12–13; at Virika Hospital, 140–141 baptisms: at Kowak mission, 69, 70t; in Nigeria, 93; at St. Luke’s Hospital, Anua, Nigeria, 98 Baptists, 14 Baskerville, Father Edward, 74 Bateman, Fiona, 14, 96

219

220

INDEX

Bayly, C. A., 3 Benedict XVI (pope), 164; American sisters criticized by, 170 Berekum, Ghana: Medical Mission Sisters in, 33. See also Holy Family Hospital Berekumhene, Nana, 33, 35 Biafra, 100; independence declared by, 101. See also Nigerian Civil War Biafran Authorities, supplies confiscated by, 114 Biafrans: health care workers, 106–109; relief work of, 109 bilharzia, 75 biomedical model, 52; and Catholic ethos, 72; and decolonization, 120; in independent Africa, 15; in nurse training schools, 46 biomedicine: access to, 160; in hospitals, 157; integration of indigenous healers and, 150 bishops: African, 63; Ghanaian, 56; Pan African meeting of Roman Catholic, 104n96 blind obedience, doctrine of, 19 Böhmig, Christine, 47 the Bono, 131 Borromeo, Sister M. Charles, 20 Boteler, Father William, 87 Bowes, Sister Catharine Maureen, 67, 71, 73, 75 Britain, and Nigerian Civil War, 111–112 British General Nursing Council, 99 Brong-Ahafo Regional Integrated Development Program, 131 Bronk, Bishop, 37–38 Bruchhausen, Walter, 123 Buckley, William F., Jr., 87 Byrne, Father Tony, 111 Byrnes, Timothy A., 86, 163 Calabar, Nigeria, 93, 94, 97 Camara, Archbishop Dom Helder, 89 Canairelief, and Nigerian Civil War, 111 Canon, Sister M. Stanislaus, 67 capping ceremonies, 48 Capuchins, 66 Caritas, in Nigerian Civil War, 101, 107 Carr, Burgess, 89 catechists, Maryknoll sisters as, 25 Catholic Campaign for Human Development, in U.S., 85 Catholic Church: in Africa, 87, 161; American sisters’ status in, 17; Canon Law, 13; and conflict between sisters and clerics, 170; gender ideology of, 30; international relief agency of, 79; in Nigeria, 92, 117; in Nigerian politics, 96; and nursing sick, 19; pro-natalist policy of, 61; racial superiority of, 113; and role of missionary sisters, 14; in Tanganyika, 65; in Tanzania, 84; as transnational organization, 4, 24. See also Vatican Catholic ethos, and biomedical model, 72

Catholic Foreign Mission Society of America, 12 Catholic health services, in sub-Saharan Africa, 160–161 Catholic hospitals, 58; in Africa, 2; in Nigeria, 93, 95; during Nigerian Civil War, 115; religious rituals at, 43; restricted visiting hours at, 44–45; role of sisters at, 44; women in, 22. See also hospitals; mission hospitals Catholicism: and indigenous women, 23; for Nigerians, 168–169; pre-Vatican II, 37 Catholic Medical Mission Board, 22 Catholic medical missions: Africans’ role in, 156; background of, 10–14; transformations in, 3 Catholic missionaries: beliefs of, 12; in war zones, 119; after World War II, 160 Catholic missions: and indigenous medicine, 121–122; and social justice, 157–159; in sub-Saharan Africa, 153–159; transnational story of, 161–162 Catholic missions, post-1945: and African theology, 21; and American civil rights movement, 20; changes in, 22; decolonization and independence, 14–16; and expanding education for sisters, 16–17; and increasing ecumenism, 16; and Second Vatican Council, 18–20 Catholic Relief Services (CRS), 79, 88 Catholics: cooperation with Protestants, 125–128; in Nigeria, 94; spheres of influence developed by, 14 Catholic sisters: change in mission for, 150, 158; compared with Protestant, 155–156; as ideal missionaries, 7; intercultural exchanges of, 2; and male hierarchy, 13 (see also sisters); priority issues for, 162; prohibited from practicing medicine, 152 (see also specific orders); in Tanzania, 91. See also sisters Catholic Student Mission Crusade, 12 celibacy, 7; for Nigerians, 169 Center for Human Integration, U.S., 137 Center for Scientific Research into Plant Medicine, Ghana, 133 Cesarean sections, 59, 74 chastity, for Nigerians, 169 Chicago, IL, Catholic hospitals in, 30 childbearing, hospitalization of, 59 China: American Catholic mission group in, 66; Maryknoll Sisters in, 25 cholera, 142 Christensen, Torbin, 8 Christian Council of Nigeria, 96 Christianity: in Africa, 167; in Tanzania, 90 Christian Medical Commission (CMC), 121, 125; joint planning with, 126, 128; on primary health care, 150–151 Christian Medical Worker’s Conference (1962), 57 Christian missionary movement: criticism of, 9; in Nigeria, 93

INDEX

“Christian presence,” 159 Christians, on African continent, 14 circumcision, female, 148 civilization, rhetoric of, 158 civil rights movements, 125; American, 20 Clark, Sister Maura, 86 clergy: indigenous, 16; in Uganda, 138. See also specific orders Clifford, Sister M. Conrad, 109, 110 clinics: biomedicine in, 157; in colonial Tanzania, 65; community support of, 77–78; expansion of, 59; mission, 16; mobile, in rural Tanzania, 68; “problem” cases at, 46; in rural Tanzania, 65; Tanzanian assistants in, 75–76. See also dispensaries; safari clinics colonial governments, relationship with missionaries of, 24 colonialism: and arrival of missionaries, 9; “indirect rule” of, 6, 33; mission work and, 8; and postcolonization, 168; and traditional medicine, 168. See also decolonization colonial medical services, in sub-Saharan Africa, 4 colonial period, training of medical assistants in, 76 Comaroff, Jean, 8 Comaroff, John, 8 co-missionaries, Nigerian nurses as, 95 Commonwealth Medical Conference, 1968 report of, 142–143 community: and decision making, 159; use of term, 176n15; value of, 147 community health workers (CHWs): in Ghana, 135, 136; in Uganda, 162 community leaders, in mission medicine, 156 complementary medicine, 137 condescension, feelings of, 158 Conference of Major Superiors of Women (CMSW), 17 Congo, 11; childbearing in, 59 congregation, use of term, 176n15 Congregation for Evangelization of Peoples, 11 Congregation for Propagation of Faith, 30 Congregation of Handmaids of Holy Child Jesus, 12 congregations: development of different women’s, 28; globalization of, 153–154; growth of women’s, 29; multinational, 6; race and class in, 13 Connelly, Cornelia, 181n60 Contact (CMC journal), 134 contraception: Catholic Church’s teaching on, 164; and Catholic policies, 61; as focus of Catholic Church, 170; and indigenous healers, 133 Convention People’s Party, 49 conversion: and conquest, 9; at Kowak mission, 74; as mission goal, 95; in Nigeria, 94; rhetoric of, 158

221

cooperation, transnational, 6 Cosgrove, Sister Pharmacist Joan, 105 cultural conflict, in mission medicine, 79–83 culture brokers, 175n6; health professionals as, 105; sisters as, 110 customs, understanding local, 147–148 Daughters of Divine Love, 117 Daughters of Mary, Mother of Mercy, 117 Dean, Sister Doctor Pauline, 102–103, 104, 105, 112, 146–150 Debets, Therese, 45–46 decolonization, 5, 6, 14–16, 19; and biomedicine, 120; and Catholic Church, 9; Catholic missioners during, 153; gendered barriers created by, 23; and health facilities in Nigeria, 95; in sub-Saharan Africa, 1; in Tanzania, 76 Dengel, Mother Anna, 2, 3, 13, 14, 26, 35, 37–38, 122, 152, 153 D’Errico, Sister Paula, 35, 40f, 50 Devane, Sister Raphael, 35 development, use of term, 89 development rhetoric, after World War II, 85 Dholuo (Luo) dialect, 68 Dickson, Dwesi, 21 dictatorships, gendered barriers created by, 23 Digby, Anne, 10, 50, 75, 76, 105 disease: endemic to sub-Saharan Africa, 39; in Tanzania, 145 dispensaries: in rural Tanzania, 65, 66, 67; in sub-Saharan Africa, 64; for training, 68. See also clinics; Kowak dispensary dispensary, use of term, 193n3 doctor-patient relationship, with mothers at Holy Family Hospital, 39, 40f, 41 Dogge, Sister Dominica, 140–141 Dolan, Jay P., 29 Dominicans, 11 Dooley, Sister Elizabeth, 102 Doud, Sister Joan Marie, 140, 141–142 Dries, Angelyn, 10, 155, 159 Drobo clinic, 45, 59 drought, in Ghana, 126, 159 ecological justice, 163 Ecumenical Association of African Theologians (EAAT, 1977), 21 Ecumenical Association of Third World Theologians (EATWOT, 1976), 21 ecumenism, 12; of 1962, 57; growing worldwide, 16 Edinburgh World Mission Conference (1910), 16, 18 education: health, 77, 126; role of nurses in, 8–9. See also nurse training schools Egwuonwu, Therese, 28 Ekechi, F. K., 93 El Salvador, 86

222

INDEX

Emekuku, Holy Rosary Hospital at, 99, 107, 115, 118 English language, in Catholic schools, 24 Enrolled Nursing (EN) Program, at Holy Family Hospital Nurse Training School, 51 Enujiofor, Sister Maria Chinweze, 167 Episcopal Conferences of Africa and Madagascar, 2010 Symposium of, 1 Eronini, Adeline, 28 Essien, Sister Agnes Maria, 27, 116 Evangelii Gaudium (Francis I), 170 evangelism, 62; broader meaning of, 163; in Tanzania, 66 Ezeh, Cecilia, 28 family planning program: in Ghana, 60–61; voluntary, 60. See also contraception; natural family planning famine: and Biafran airlift, 111–112; during Nigerian Civil War, 102, 103 feedings, during Nigerian Civil War, 109 Feierman, Steven, 69, 82, 122, 150, 151 Fidei Donum (encyclical), 16, 32 field worker, in primary health care, 135 Flieger, Sister Laetitia, 35 Ford, Sister Ita, 86 Foreign Mission Sisters of St. Dominic, 25, 64. See also Maryknoll Sisters Franciscan Missionaries of Mary, 13 Franciscans, 11 Francis I (pope), 170 Frazer Commission (1954), 142 Friere, Paolo, 89, 149 Garneti, Sister Margaret, 148, 149 gastrointestinal disorders, in children, 78 Gates, Sister Doctor Jane, 39, 41, 57, 62, 125; visits to outlying clinics of, 45 gender history, health care and religion in, 30 genocide, of Nigerian Civil War, 111 germ theory, 15 Ghana, 7, 32; coups d’état in, 58; drought in, 126, 159; family planning program in, 60–61; health care facilities in, 56–57; health system, 161; independence of, 15; infant mortality in, 160; medical and nursing development in, 33–35; Medical Mission Sisters in, 26; Medical Mission Sisters’ new hospital in, 24; Ministry of Health, 135; National Health Planning Unit, 130; nursing in, 32–33, 47; rural health care system in, 46 Ghana Association of Psychic and Traditional Healers, 130, 131 Ghana Registered Nurses Association, 136–137 Gifford, Paul, 92, 161 Gill, Sister Nurse Christine, 105 Gilson, Lucy, 161 Gleason, Philip, 18 global health, 162; and “reverse mission,”

163–164, 164f; role of contraception in, 164–165, 166f globalization, cultural, 153 Gold Coast, 32. See also Ghana Good, Charles M., 10, 76, 150 gospel, in inculturation process, 21 Government Test for Pupil Nurse Index, in Ghana, 48 Gray, Richard, 136 Grealy, Sister Josephine, 145 Great Depression, 34 Gregory XV (pope), 10–11 Gutierrez, Father Gustavo, 198n83 habits, religious: of Nigerian sisters, 169; replaced, 62, 86 Hanang District, Tanzania, training of health workers in, 148–149 Handmaids of Divine Redeemer, 13 Handmaids of Holy Child Jesus, 117 Hanks, Sister Alice, 42f, 50 Hastings, Adrian, 9 healers: in community-centered healing system, 151; female, 123; influence of African, 157; traditional, 120 healers, indigenous: collaboration with, 157; during colonial period, 122; government recognition of, 133–134; integration of biomedicine and, 150; mutual exchange of knowledge with, 130; partnering with, 131–132; perspective of, 133–135; Primary Health Training program for, 130; referrals to, 134; sharing knowledge with, 120–124; sisters’ understanding of, 146; training of, 128; vs. dispensaries, 124; WHO’s endorsement of, 130 Healers of Ghana (film), 133, 134 healing systems: holistic, 167, 168; local, 128; modern and traditional, 135; pluralistic, 72 health: and poverty, 151; and socioeconomic factors, 143 health care: Catholics in, 72; colonial European model of, 64; communitybased primary, 15; as human right, 126; infrastructures established for, 153; at local level, 64; shifts in provision of, 155; in Tanzania, 65; transnational, 162 health care, in sub-Saharan Africa, 4, 24–25; and Maryknoll sisters, 25–26; and Medical Missionaries of Mary, 26–27; and Medical Mission Sisters, 26; and Missionary Sisters of Holy Rosary, 27–28; and Sisters of Immaculate Heart of Mary, 28 health care ministry, in Tanzania, 66–67 health care practitioners, Westerneducated, 2 health development, in Tanzania, 90–91 health education, 77, 126 health facilities, access to European, 34 Healy, Sister Camillus, 37, 48, 49, 50, 126

INDEX

Heerey, Archbishop Charles, 13, 115, 168 hepatitis, 53 herbalists: African, 121; Tanzanian, 147 herbal medicines, 137; clinical efficacy of, 134 Hirschboeck, Sister Elizabeth, 25 history: gender, 30; transnational, 3–4 HIV/AIDS epidemic, 6, 160, 164 Hogan, Mrs. (Nigerian midwife), 105, 113 Hokkanen, Markuu, 8, 76 Holy Family Hospital, Berekum, Ghana, 33, 35–46, 44f, 135, 161; all-Ghanaian staff of, 161; arrival of first sisters at, 35; authority structures at, 36–37; financing projects at, 53; Ghanaian physicians at, 63; Ghanaian student nurses at, 41, 42f, 43f; and Ghanaian tradition, 37; Governing Board of, 58; laboratory positions at, 52; land and buildings ceded to MMS at, 35; liturgical celebration at, 42; medical services at, 39; medical students at, 58; midwifery training program at, 59; operating room technicians trained at, 41; patients treated at, 60t; physicians at, 36–37; public health program of, 126; reducing maternal and infant mortality at, 59–61, 60t; restricted visiting hours at, 44–45; staffing issues at, 53–56, 54f, 55t; statistics for, 36, 36t; training in auxiliary positions at, 59; and transnational collaborations, 56–59; water supplies at, 36 Holy Family Hospital, Techiman, Ghana, 35, 130, 131 Holy Family Hospital Nurse Training School: biomedical model in, 46; costs at, 51; criticism of, 49; curriculum of, 50–51; failure to pass exam at, 49; QRNs obtained at, 51; success with exam at, 50–51 Holy Family Hospital School of Nursing, elevated to college status, 63 Holy Family Joint Hospital, Ikom, Nigeria, 100 Holy Ghost Fathers, 11, 66; in Nigeria, 93; during Nigerian Civil War, 107 Holy Ghost mission, in 1905, 93 Holy Rosary Hospital, at Emekuku, 99, 107, 115, 118 Holy Rosary Sisters, 13, 27; Emekuku hospital of, 99, 107,115, 118; medical facilities established by, 97; in Nigeria, 92, 94, 96–97; during Nigerian Civil War, 100–101, 106, 107, 108f home visits: for health education, 77; at Kowak dispensary, 69, 69t homosexuality, as focus of Catholic Church, 170 Hornung, Sister Maria, 54f, 139f hospice, in Nigeria, 96–97 hospitals: biomedicine in, 157; blurring of professional boundaries in, 154–155; in colonial Tanzania, 65; of Ghanaian

223

government, 56–57; of Holy Rosary Sisters, 27; mission, 16, 65; nursing schools affiliated with, 48; Protestant mission, 22; in Uganda, 137, 142–143; and war, 145. See also Catholic hospitals; mission hospitals human rights, 125; role of women in, 31 Hunt, Lynn, 3 Hunt, Nancy Rose, 10, 59, 68, 74 Hutchison, William R., 8 Ibos, 94 Ibo tradition, indigenous women in, 23 Igbo (or Ibo), 27–28 Igbos (Ibos), 94 Ihiala hospital: bombing of, 110; during Nigerian Civil War, 107 IHMs. See Immaculate Heart of Mary (IHM) Sisters Illiffe, John, 10 Immaculate Heart of Mary (IHM) Sisters, 6, 13, 28, 96; in Nigeria, 92, 94, 167, 168, 178n26; during Nigerian Civil War, 115 Immaculate Heart Sisters, Tanzanian, at Kowak facility, 83 Immaculate Heart Sisters of Africa, 68 immunizations, for tuberculosis, 126 income inequality, 163 inculturation, 21 independence, 5, 6, 14–16; and expansion of health care work, 160; in sub-Saharan Africa, 1. See also decolonization India, Medical Mission Sisters (MMS) in, 26 indigenous practitioners: secrecy of, 138; and Western practitioners, 129–130. See also healers, indigenous “indirect rule” of colonialism, 6, 33 Industrial Relations Act (1960), 54 Infant Malnutrition Research Center, in Kampala, 143 infant mortality: in Ghana, 34, 59, 160; in Nigeria, 160; in postcolonial Africa, 15; in sub-Saharan Africa, 159–160; in Tanzania, 78 inflation, in Ghana, 126, 128–129 international agencies, and community participation, 150 International Committee of Red Cross (ICRC), and Nigerian Civil War, 105, 111 International Conference on Primary Health Care (Alma Ata, 1978), 128–129, 130, 159 International Medical Missionary Training Center, in Drogheda, 17, 27 Ireland: authoritarian and hierarchical model in, 29; and Catholic Emancipation, in 1829, 29; Catholic hospital system in, 22; “spiritual empire” of, 96 Irish Catholic Church, 29; global outreach of, 390 Irish Concern, 119

224

INDEX

Irish mission work: in Nigeria, 93, 94; in Uganda, 138 Irish priests: impact of Nigerian Civil War on, 112–115; Joint Biafra Famine Appeal of, 111; during Nigerian Civil War, 111–112 Irish sisters: in Nigeria, 94–95; return to Nigeria of, 116 Isichei, Elizabeth, 9 Islam, expansion in Africa of, 22 “jathak,” 123 Jennings, Michael, 65 Jesuits, 11 John XXIII (pope), 18 Joint Church Aid (JCA) group, and Nigerian Civil War, 111 Joint Working Group, 125 Jones, David S., 15 Joseph Therese, Sister, 109 Justice and Peace Commission, in Rhodesia, 89 Kampala, Uganda, Infant Malnutrition Research Center in, 143 Kasanga, Uganda, dispensary in, 141–142 Kearney, Mother Mary Kevin, 12 Kenya: Maryknoll Sisters in, 26; Medical Missionaries of Mary in, 27; Medical Mission Sisters in, 26 Kershbaumer, Sister Rose, 120, 141 Kirk, Balfour, nursing curriculum and standards of, 47 Kirsch, Sister Joan Michel, 67f Kituvo Mission Hospital, Masaka, Uganda, 142–150, 162; indigenous staff at, 156; international donors for, 143–144; mobile program at, 162; Nutrition Unit at, 143–144; overcrowded maternity and children’s wards at, 146; and war, 145 knowledge: cross-national flows of, 152, 156; role of nurses in transfer of, 8–9; shared with indigenous healers, 120–121; translation of medical and religious, 156; transnational, 144 Koehlinger, Amy, 20 Kokofu Leprosarium, 35 Korea, Maryknoll Sisters in, 25 Korle Bu Teaching Hospital, 34 Kowak dispensary, 66; equipment at, 69, 71, 76–77; finances of, 69, 71; government assistance denied to, 69, 71; government funding for, 76; languages at, 71; Maryknoll Sisters’ departure from, 91; in 1961, 76–77; statistics for, 69, 70t Kowak Maternity Hospital, 82–83 Kowak Mission, Tanzania, 67–75; conversions at, 74; cultural conflict in, 79–83; government funding denied to, 74; location of, 68–69; Maryknoll Sisters at, 122–124; miracles at, 72–84; transportation arrangements of, 69 Kumasi: government hospital at, 34, 51; nurse training school in, 47

Kumasi, bishop of, 38–39, 134 Kunkler, Sister Miriam Rachel, 84 kwashiorkor, 88; in Nigerian Civil War, 105 Lady of Lourdes Hospital, Drogheda, Ireland, 17 Lagos, Nigeria, British colonization of, 93 Larkin, Emmet, 29 Latin America: liberation theology in, 86, 87, 198n83; missions in, 86; sisters from, 165, 167 lay employees, 54, 55t, 56 lay missioners, 7, 159 Leadership Conference of Women Religious (LCWR), 29, 170 Leo XIII (pope), 18 leprosy, 4, 73, 100; diagnosis of, 68, 73; at Kowak facility, 77; in Nigeria, 94, 95 liberation theology, 21, 84, 89, 163; in Latin America, 87, 198n83; and Maryknoll Sisters, 87, 90, 155 Liberia, African Christians in, 11 life expectancy: in Ghana, 34; in postcolonial Africa, 15–16; in subSaharan Africa, 159–160 Litsios, Socrates, 128 Little Sisters of St. Francis, 12 Luwum, Anglican Archbishop Janani, 138 Mac Curtain, Margaret, 13 Macrae, Joanna, 161 Magray, Mary Peckham, 29 malaria, 53, 75, 109, 142; in children, 78; at Kowak dispensary, 77 Malawi: Medical Missionaries of Mary in, 27; Scottish missionaries in, 8–9 malnutrition: in children, 78; in Ghana, 126; teaching about, 144 malpractice insurance, lack of, 46 Manton, John, 9 marasmus, in Nigerian Civil War, 105 Martin, Marie, 14, 26–27, 97 Maryknoll Fathers, 12, 71 Maryknoll Magazine, 163 Maryknoll motherhouse, Pres. Nyerere’s speech at, 85–86 Maryknoll Sisters, 6, 12, 25–26, 29, 64; in Africa, 66; arrival in Kowak of, 66; General Assembly of, 84–85; and indigenous medicine, 122–124; in justice and peace programs, 163; Kowak Mission of, 67–75; and liberation theology, 86, 87, 155; mission redefined for, 88; newsletter of, 88; politicization of, 89–90; and politics, 80–88; Regional Rustlings of, 151; “reverse mission” of, 163; in Ujamaa, 87–88; work of, 65 mass, Catholic, African worship practices in, 169 maternal and infant health care: , at Kowak dispensary, 78; in Tanzania, 68 maternal mortality, in Ghana, 34, 59 Maude Commission, 1952 report of, 34, 150

INDEX

McAuley, Catherine, 29 McCauley, Rev. Vincent, 13 McCullagh, Sister Eugene, 102, 103 McGinnis, Sister Sheila, 137 McLaren, Dr. Agnes, 13, 26, 28 McLaughlin, Sister Janice, 89–90 McSweeney, Sister Doctor Leonie, 102, 112 measles epidemic, in Ghana, 126 medical care, religious commitment and, 74. See also biomedicine; health care medical costs, rising, 125 Medical Missionaries of Mary (MMM), 6, 13, 14, 88, 151; and ecological justice, 163; focus on community health of, 144; leprosy facilities administered by, 100; in Nigeria, 92, 94, 97–100, 120; during Nigerian Civil War, 100–101, 104–106, 117; self-sufficiency of, 144; social justice issues of, 162; St. Luke’s Hospital established by, 98–99; Visitation produced by, 95; work with women and children of, 97–98 Medical Missionaries of Mary (MMM) and primary health care, 119; collaborations, 128; emphasis on, 145–146; in Uganda, 142–150 Medical Mission Sisters (MMS), 2, 6, 14, 26, 29; arrival in Uganda, 138; in Berekum, Ghana, 33; changing mission of, 62, 158–159; collaborations, 128; “Common Purpose” of, 62; Development Dept. of, 53; founding of, 3; healing vs. medical mission of, 61–63; Holy Family Hospital handed over by, 161; lay attire for, 62; and medical hierarchies, 38–39; newsletters of, 151; nurse training schools of, 50; political involvement of, 164, 164f; and primary health care, 135, 140; and rural health care, 129–130; and traditional healers, 120, 137; in Uganda, 13, 137–142, 161; view of Africans of, 121–122 medical mission work, transnational character of, 1 medical profession, women in, 30–31 medicine: curative vs. preventive, 150; in Gold Coast, 33–34; herbal, 134, 137; local, 122; in postcolonial Africa, 15; in subSaharan Africa, 121. See also biomedicine medicine, indigenous, 121–122; clinical efficacy of, 122–123; learning about, 123, 124; and Maryknoll Sisters, 122–124; research in, 128. See also healers Médicins sans Frontières (Doctors without Borders), 119 Midwifery School at Holy Family Hospital, 52 midwives: African, 5; Catholic sisters as, 152–153; in former British colonies, 23; Ghanaian, 61; restrictions on nuns as, 28; sisters as, 14 miracles, in Catholic teachings, 72–73 Mirau (herbalist), 147 Misereor (German agency), 138, 146, 161

225

mission: interpretation of, 169; “reverse,” 163–164 missionaries: historiography of, 8; and “otherness,” 5, 121; as racist colonial oppressors, 85; as spokespersons for humanitarian interests, 119 Missionary Sisters of Holy Rosary, 6, 27–28 Missionary Sisters of Our Lady of Africa, 11, 181n52 missioners: American, 22; Catholic compared to Protestant, 155–156; cultural globalization as, 153; influence of Africans on, 122; in Nigerian Civil War, 106, 107; use of term, 7 mission hospitals: African patients of, 157; after African independence, 125; funding of, 145; indigenous nurses trained in, 47; and local traditions, 124; in Nigeria, 96; pluralistic healing in, 72; staffed with Africans, 151. See also Kituvo Mission Hospital mission medicine, cultural conflict in, 79–83 mission messages, in Tanzania, 90 mission movement: outcomes of, 159–162; transformation in, 159 mission personnel, globalization of, 153–154 missions: changing focus of, 153; legacies of, 152; in Nigeria, 118–119; in Tanzania, 65; training for, 149; transformation of, 5; in Uganda, 140 mission work: competing interpretations of, 8–10; government involved in, 81 mobile program, at Kituvo Hospital in Uganda, 162 modernity, biomedicine in, 157 modernization, of society, 5 Mohammedanism, 14 “Mongangas,” 123; sisters as, 123 Moran, Sister Margaret, 135–136 mother-baby bonding, 148 motherhood, Catholic Church’s emphasis on, 74–75 mothers, African, 41 Mphahlele, Es’kia, 88 Murphy, Sister Brigidine, 102 muscle therapy, 137 Muslim women, health care for, 26 National Catholic Secretariat: Dept. of Health of, 58, 122; National Medical Advisory Board of, 58 nationalist movements, 49 natural family planning, 165. See also contraception Ndubuaku, Sister Sylvia, 167 Neitz, Mary Jo, 5 Nesta, Sister Mary, 167 The New Nuns (Borromeo), 20 Newpower, Father, 163

226

INDEX

Nigeria, 7; Catholic Church in, 92, 96, 117; Catholic hospitals in, 95; Holy Rosary Sisters in, 96–97; IHM Sisters in, 167, 168; independence of, 15, 93; indigenous sisters in, 117; infant mortality in, 160; influence of white missionaries in, 167–168; Irish expelled from, 115, 118; Irish mission work in, 93, 94, 96; Medical Missionaries of Mary in, 26, 27, 97–100; minority groups of, 100; mission hospitals in, 96; mission nursing and medicine in, 92–96; missions in, 118–119; Muslim region of, 94; nuns in, 163; pluralistic medical system in, 167; priests and sisters expelled from, 113–114; religious institutions in, 118; sisters’ relief work in, 117 Nigeria Medical Dept., Catholic Secretariat of, 98 Nigerian Civil War, 92, 96, 146, 163; Biafran airlift during, 110–112; “Biafran War Diary” during, 102–104; Catholic hospitals after, 115; Catholic medical institutions during, 118; consequences for Irish religious, 112–115; famine during, 102, 103; health care during, 109; hospitals bombed during, 101, 102; loss of life in, 114; and Medical Missionaries of Mary, 104–106, 117; Nigerian sisters during, 115–117; nursing and medical care during, 100–114; oil interests and, 101; refugee camps during, 103–104; relief operation during, 103, 112; supplies confiscated by government during, 114; world opinion concerning, 119 Nigerian Handmaids of the Holy Child Jesus, 101 Nigerian sisters, 94–95; mission health care projects of, 119; during Nigerian Civil War, 115–117; transnational links of, 118 Nigerian Union of Nurses, 96 Nightingale pledge, 52 Nkiru, Sister Maria, 169 Njoku, Sister M. Therese, 115 Nkrumah, Prime Minister Kwame, 32, 34, 49, 58 Nolan, Sister Doctor Margaret Mary, 98, 120 nongovernmental organizations (NGOs), 128, faith-based, 85 Nordic Church Aid, and Nigerian Civil War, 111 North America, Catholic mission work in, 11 Novak, Michael, 87 nun, use of term, 176n15 The Nun in the World (Suenens), 17 nuns: in Africa, 154; in civil rights movement, 20. See also sisters; specific orders Nurse Ordinance, in Ghana, 47 nurses: African, 5; in Ghana, 32–33; Maryknoll Sisters as, 25; Nigerian, 95 Nurses and Midwives Council for Ghana, 52

Nurses Board, in Ghana, 47 nurse training, in Africa, 15 nurse training schools, 46–47; established by MMM, 97; for indigenous nurses, 47–48; at St. Luke’s Hospital, Nigeria, 99. See also Holy Family Hospital Nurse Training School nursing: changing status of, 47; in former British colonies, 23 Nursing Council in Ghana, 36 Nursing Council of England and Wales, 47 Nursing Council of Gold Coast syllabus, 50 Nursing Council of Nigeria, 9, 115 nursing education, 149. See also nurse training schools nursing profession, women and, 30–31 nursing schools, colonial, 99 nutrition: education, in Ghana, 135; and expansion into primary health care, 160; health classes on, 79; instruction, 126, 127f; surveys, by village health workers, 149 Nutrition Unit, at Kituvo Hospital, 143–144 Nyerere, Pres. Julius, 76, 77, 84, 85; socialism of, 91; Ujamaa development scheme of, 87–88 obedience, for Nigerians, 169 Obiaga, Ndubisi, 111 Obote, Pres. Milton, 137 O’Brien, Sister Mary Agatha, 30 O’Brien, Sister Nurse Margaret, 78, 83 obstetricians: restrictions on nuns as, 28; sisters as, 14, 152–153 obstetrics, Medical Missionaries of Mary’s focus on, 98 Odili, Evangeline, 28 oilfields, eastern Nigeria’s, 101 Ojeleye, Olukunle, 111 Oju, Ogwu, 23 Ojukwu, Col. Chukuemerka Odumegwu, 106 Okafor, Sister Nkiruka, 168, 169 Okkenhaug, Inger Marie, 9 Okoye, Bishop Godfrey, 117 Okwu, Augustine S. O., 9 Omenka, Nicholas, 25 Onokerhoraye, Andrew G., 94 Onovo, Sister Maureen Bernardine, 167 Onyiuke, Helen, 28 Opoku, Dr. Kofi Asare, 133, 134 oppression, new focus for, 149 oral histories, 217n11 oral rehydration solution, 132 Oranu, Sister Clara, 28, 96 order, use of term, 176n15 Orta, Andrew, 8 Otoo, S. N., 34 Otuonye, Susan Mary, 28 outreach clinics, 126. See also safari clinics outstation clinics, established by Medical Missionaries of Mary, 97

INDEX

paganism, 14 Pan-African Conference of Third World Theologians (1977), 21 papal encyclicals, in 1950s, 16, 20. See also specific titles parasites, intestinal, 41 patient assessment, conflict over, 80–82 Paul VI (pope), 21; Humananae Vitae of, 61; and Nigerian Civil War, 112–113; papal encyclicals of, 20; Populorum Progressio of, 85 payment systems, and cultural conflict, 82 Pedagogy of the Oppressed (Friere), 149 Peel, J. D. Y., 9 Pelletier, Sister Doctor Fernande, 41, 57–58, 161; visits to outlying clinics of, 45 pharmacy assistants, in Uganda, 54f the Philippines, Maryknoll Sisters in, 25 Phillipson, Sir Sydney, 95 physicians: Ghanaian, 63; Protestant, 65. See also sister physicians Piette, Sister, Carla, 86 Pillsbury, Barbara, 142 Pirouet, M. Louise, 138 Pius XI (pope), 12, 18 Pius XII (pope), 32 pneumonia, in children, 78 polygamy, 121 the poor: problems of, 128; support for, 86 population-bed ratio, in Ghana, 34 population growth, in Ghana, 60, 128–129 postcolonial discourse, role of mission work in, 8 poverty: and expansion into primary health care, 160; and health, 151; new focus for, 149; for Nigerians, 169 “preferential option for the poor,” 198n83 prenatal care: availability of, 61; increase in, 59; positive outcomes of, 15 prenatal clinics: at Kowak dispensary, 70t, 74; in Tanzania, 77 Presbyterians, 14 Preusser, Sister Ursula, 161 prevention activities, as national goals, 78. See also primary health care PRHETIH program, in Techiman, 130, 135; healers trained in, 132–133; pretraining survey of, 131–132; team members of, 134; topics in, 132t Pridie, Dr. Eric, 66 priest healer, Ghanaian, 133 priests: expelled from Nigeria, 113–114; international political activism of, 118; Irish, 111, 112–115; Maryknoll Fathers, 12 primary health care (PHC): formally introduced in Ghana, 130; selective, 151; shift of emphasis to, 154; transnational collaboration in, 120–121; in Uganda, 137–150 Primary Health Care Links (periodical), 146, 151; female circumcision discussed in, 148; health workers training in, 148–149;

227

on nursing education, 149; on poor and oppressed, 147 primary health care projects, self-sustaining, 149 private patients, ward for, 53 Propaganda Fide, 10–11 proselytism, pejorative understanding of, 125 Protestant missionaries, beliefs of, 12 Protestant missions: in Africa, 11; hospitals of, 22; in Nigeria, 93; training of medical assistants in, 76 Protestant physicians, in Tanganyika, 65 Protestant relief work, and Nigerian Civil War, 101 Protestants, 14; cooperation with Catholics, 125–128; mission historiography on, 8–9; in Nigeria, 94; spheres of influence developed by, 14 Protestant student movement, 12 Pruitt, Sister Jean, 88 public health: Catholic sisters’ focus on, 154; in Ghanaian villages, 126; investment in, 159; in Tanzania, 76–79 Puszcz, Sister Doctor Marian Jan, 74, 80, 81, 82, 83 qualified registered nurse (QRN) programs: in Ghana, 47; at Holy Family Hospital, 48; sister tutor for, 50 Rachel, Sister Miriam, 86 racial justice, 20 Radharc, 107, 110 Ranger, Terence, 9, 65, 71 reflex therapy, 137 refugee camps, during Nigerian Civil War, 102, 107 Regional Rustlings (newsletter), 88 Reid, Richard J., 159 relief organizations, in Nigerian Civil War, 119 relief workers: missionaries as, 9; during Nigerian Civil War, 111 religion: African faiths, 158; freedom of, 125; and medical science, 2–3; in Nigeria, 118; in Tanzania, 90–91; transnational, 165 religious communities, and racial superiority, 23 religious congregations, numbers for, 7 religious liberty: as human right, 18. See also liberation theology religious life, 152 religious organizations, transnational, 168 religious rituals, at Catholic hospitals, 43 religious vocations, on African continent, 2 respect, feelings of, 158 “reverse mission,” 163–164 Rhodesia, Maryknoll Sisters in, 26 robberies, in Berekum, Ghana, 49

228

INDEX

Robert, Dana L., 10, 11, 22, 156 Rogers, Sister Mary Joseph, 25, 26 Roman Catholic Church. See Catholic Church roundworm infection, at Kowak facility, 77 RTE, 107, 110 Rubanda, Uganda, MMS health center in, 161 Rudin, Bishop John, 81, 82–83 rural health care system, in Ghana, 46 Russell, Mother Baptist, 30 Ryan, Agnes, 27 Ryan, Msgr. John, 18 safari clinics: in rural Tanzania, 78, 79, 83; in rural Uganda, 138, 139f St. Luke’s Hospital, Anua, Nigeria, 98–99; after Nigerian Civil War, 116; lack of government support for, 99; Nurse Training School of, 99; sources of income for, 99–100 Salvatorian Mission Warehouse, in Wisconsin, 145 Sambo, Luis Gomes, 64 San Francisco, CA, Catholic hospitals in, 30 sanitation: in disease prevention, 15; in Ghana, 135; health classes on, 79 Sanneh, Lamin, 9 Sarpong, Bishop Peter, 134 scabies, treatment for, 126 schistosomiasis, at Kowak facility, 77 schools, in Tanzania, 90. See also nurse training schools Schram, Ralph, 93, 99 science: and medicine, 42–43, 43f; in postcolonial Africa, 15; in Tanzania, 90 screening, local Ghanaians trained for, 126 Second Vatican Council. See Vatican II secular society, mission sisters in, 17 self-rule, 1 Selma, AL, civil rights march, 20 Shanahan, Bishop Joseph, 27, 93, 94, 96 Shean, Sister Catherine, 50 Shirati, Tanzania, Mennonite facility at, 68 Shirati Hospital, 73 Sierra Leone, African Christians in, 11 sister, use of term, 176n15 sister doctors, 151; in Nigeria, 97; in Nigerian Civil War, 104 Sister Formation Movement, 17 sister midwives, 154; Nigerians as, 119 sister nurses, 154; indigenous healing measures used by, 124; Nigerians as, 119 sister physicians, 154; Nigerians as, 119 sisters: African, 155, 165, 167; as agents of change, 89; changing attitudes of, 158; commonalities among, 169–170; expanding education for, 16–17; expelled from Nigeria, 113–114; humanitarian relief promoted by, 155; impact of Nigerian Civil War on, 112–115;

indigenous, 154; loss of identity for, 20; medical assistants trained by, 75; in Minneapolis, MN, 167; political involvement of, 163–164, 164f; in primary health care, 148; relationship with patients of, 147; in sub-Saharan African health care, 25; Tanzanian, 154; white habits of, 44, 44f Sister Servants of Holy Spirit, 13 Sisters of Holy Child Jesus, 181n60 Sisters of Mary Immaculate, 13 Sisters of Mary Reparatrix, 12 Sisters of Mercy, in U.S., 29 Sisters of Most Pure Heart of Mary, 13; during Nigerian Civil War, 115 Sisters of Our Lady of Apostles, 13 Sisters of Our Lady of Kilimanjaro, 12 Sisters of Our Lady Queen of Africa congregation, 12 slave trade, 17th-century, 92 smallpox vaccinations, at Kowak dispensary, 78 Smith, Ian, 89 Smyth, Sister Rosemary, 52 snake bites, traditional treatment for, 124 social injustice, 163 socialism: African, 91; in Tanzania, 90 social justice, 3; and Catholic missioners, 155; and Catholic missions, 157–159; ministries of, 169; sisters’ mobilization for, 170 Society of Catholic Medical Missionaries, 2. See also Medical Mission Sisters Society of Holy Child Jesus, 12 Solidarity with Women in Distress (SOLWODI), 165 South Africa, Medical Mission Sisters in, 26 Spanish-American War, 11 Speciosa, Sister, 141–142 Spiritans, 11, 93 spirituality, in healing process, 136 starvation, during Nigerian Civil War, 106 state registered nurse (SRN) programs, in Ghana, 47 Staunton, Enda, 111 stillbirth rate, in Ghana, 59 Stremlau, John J., 111 students, nursing: at Holy Family Hospital Nurse Training School, 48, 51–52; walkouts of, 49 Sudan, Maryknoll Sisters in, 26 Suenens, Leon-Joseph Cardinal, 17 sulfa drugs, 71 surgeons: Catholic sisters as, 14, 152–153; restrictions on nuns as, 28 surgery, patient preparation for, 81 surgical teams, all-female, 154 Swahili, 68, 76 Swedish Red Cross, 140 Sweet, Helen, 10, 50, 75, 76, 105, 124

INDEX

Tabzabua, independence of, 15 Tanganyika African National Union (TANU), 73, 83 Tanganyika (Tanzania): Maryknoll Sisters in, 26; postwar health care delivery in, 64; preventive services needed in, 66; after World War I, 66 Tanzania, 7; agents of change in, 88–91; auxiliary health care personnel in, 65; Catholic Church in, 84; colonial, 65; disease in, 145; health care in, 76, 122; independence of, 76; Maryknoll Sisters in, 26; maternal and infant health care in, 68; medical auxiliary positions in, 75–76; Medical Missionaries of Mary in, 27; nursing and medicine in, 65–67; political changes in, 84; public health in, 76–79; sisters in, 154; training of health workers in, 148–149 Tanzanian Episcopal Conference of national bishops, 83 Tanzanians, traditional beliefs of, 124 teachers, Maryknoll Sisters as, 25 team leadership, in mission, 155 the Techiman-Bono, 131 technology, reliance on, 147 Thackaberry, Mother Cecilia, 106 theology: African, 21; restricted to male clergy, 89 Town Health Committees, in Ghana, 136 Trade Union Congress (TUC), 54 traditional birth attendants (TBAs): accused of witchcraft, 136; in communitycentered healing system, 151; in Ghana, 129; training, 135–137, 146; in Uganda, 138, 140 transnational alliances, 151 transnationalism, 118 transnational links, during Nigerian Civil War, 110–111 transnational networks, of women religious, 165, 167–169 transnational processes, 3–4 transnational religious organizations, 168 Tregoning, Sister Mary Ann, 129–130, 129f, 133, 137 tribal dressers, 10 tubal ligations, 165 tuberculosis, 142; after colonization, 73; immunizations for, 126 Twomey, Sister Doctor Deirdre, 105 Twumasi, Patrick, 150 Uganda, 7; contraception in, 165; Medical Missionaries of Mary in, 27; Medical Mission Sisters in, 26, 161; nuns in, 163; primary health care in, 137–150; public health crisis in, 161 Ugandan government, hospitals prioritized by, 146 “Ujamaa”: development scheme, 84, 87–88; villages, 91, 125

229

uncertainties, medical, 82 Unified Colonial Medical Service, in Ghana, 34 United Nations, Universal Declaration of Human Rights of, 16 United Nations Children’s Fund (UNICEF), 79 United States, foreign policy of, 163 University of Ghana, medical school of, 58 upper respiratory infections, at Kowak facility, 77 urbanization, in Ghana, 128–129 Uwanuakwa, Sister Immaculata, 168 vaccinations, 78, 151 van Agtmael, Sister Margaret Mary, 35 Varkevisser, Corlien, 148 Vatican: investment in eastern Nigeria of, 113; and liberation theology, 87; and Marxism, 21; and Medical Mission Sisters, 62–63; mission territories apportioned by, 94; sisters’ medical training controlled by, 13–14. See also Catholic Church Vatican II (1962–1965), 18–20, 22, 89, 125, 155; Ad Gentes of, 18–19; Catholic social thought after, 84; and changes in mission, 117; influence on Maryknollers of, 84, 86; Lumen Gentium of, 19–20; and Medical Mission Sisters, 57; Perfectae Cariatis of, 19; sisters’ governance structures after, 155; and sisters’ mission, 162, 170; sisters’ response to, 149; and women religious, 18 Vaughan, Megan, 8, 24 Vella, Sister Jane, 88 village committees, in mission medicine, 156 village health workers: in communitycentered healing system, 151; nutrition surveys of, 149; training for, 148–149 villages, in rural Tanzania, 65 Villa Maria Hospital, Tanzania, 145 violence: acute care during periods of, 143–146; gender-based, 162 Virika Hospital, Fort Portal, Uganda, 138, 140–141 Visitation (film), 95 visiting hours, restricted, 44 Waite, Terry, 61 Walker, Sister Mary Charles, 12, 101 Warde, Sister Frances Xavier, 30 Warren, D. M., 130, 131 Webster, MMS Doctor Francis, 129 well-baby clinics: in Ghana, 135; at Kowak mission, 74; in Tanzania, 77 Whelan, Bishop Joseph, 106, 107, 111 White Fathers, 11, 181n52; in Tanganyika, 65–66 “white man’s grave,” 7 White Sisters, 11, 13, 181n52

230

INDEX

Winkelmann, Sister Margaret Rose, 67, 68 Wiseberg, Laurie, 111 witchcraft, missioners’ view of, 122 “witchdoctors,” 121; mission leaders’ view of, 123 women: Ghanaian expectations for, 60; growing educational opportunities for, 16–17; in Ibo tradition, 23; Protestant, 7; Protestant missionaries, 11; in religious life, 152; role of, 30; in 20th century, 5; in transnational church, 4 women, indigenous: congregations of, 12; nurses’ intervention in reproductive lives of, 23 women religious: in Africa, 2; and African culture, 122; changing agenda of, 19; and commonalities among sisters, 169–170; community bonds of, 163; comparisons of, 28–31; and contraception, 164; in global world, 162; mission work of, 152–153; Nigerian sisters as, 169; and outcomes of mission endeavors, 159–162; and primary health care, 121; “reverse mission” of, 163–164; transnational networks of, 165, 167–169; use of term, 176–177n15; and Vatican II, 18. See also sisters

women’s history, health care and religion in, 30 women’s rights, and medical care, 22 Worboys, Michael, 16 World Bank Structural Adjustment Programs, 159 World Council of Churches (WCC), 16, 125; and Nigerian Civil War, 101, 111 World Health Organization (WHO), 121, 155; and global health, 128; global malaria eradication program of, 78; intensive smallpox vaccination program of, 78; and Medical Mission Sisters, 159; primary health care approach of, 128; Thirtieth World Health Assembly of, 128 World War I, 9, 12 World War II, 1; health care facilities after, 160 Yancho, Paul, 111 yaws, treatment for, 71 Zanzibar, 76 Zimbabwe, Maryknoll Sisters in, 26 Zwi, Anthony, 161

ABOUT THE AUTHOR

BARBRA MANN WALL , PhD, RN, FAAN, holds the Thomas A. Saunders III

Professorship in Nursing at the University of Virginia School of Nursing. Dr. Wall received her BS from the University of Texas at Austin and her MS in nursing from Texas Woman’s University. She earned a PhD in history from the University of Notre Dame. She has published Unlikely Entrepreneurs: Catholic Sisters and the Hospital Marketplace, 1865–1925 (2005); and American Catholic Hospitals: A Century of Changing Markets and Missions (Rutgers University Press, 2011). She also is coeditor, with Dr. Arlene Keeling, of two books on the history of nursing in disasters: Nurses on the Front Lines: When Disasters Strike, 1878–2010 (2010); and Nurses and Disasters: Global, Historical Cases (2015).