The Conversion Agenda

"Freedom to convert" is counterproductive as a generalized doctrine. It fails to come to terms with the complex interrelationships between self and society that make the concept of individual choice meaningful. Hence, religious conversion undermines, and in extremes would dissolve, that individual autonomy and human freedom.

Sunday, April 29, 2007

EXPORTING FAITH: Bush brings faith to foreign aid


As funding rises, Christian groups deliver help -- with a message
October 8, 2006

This story is the first of four parts. It was reported and written by Farah Stockman, Michael Kranish, and Peter S. Canellos of the Globe Staff, and Globe correspondent Kevin Baron.

LAKARTINYA, Kenya -- The herders of this remote mountain village know little about America, but have learned from those who run a US-funded aid program about the American God.

A Christian God.

The US government has given $10.9 million to Food for the Hungry, a faith-based development organization, to reach deep into the arid mountains of northern Kenya to provide training in hygiene, childhood illnesses, and clean water. The group has brought all that, and something else that increasingly accompanies US-funded aid programs: r egular church service and prayer.

President Bush has almost doubled the percentage of US foreign-aid dollars going to faith-based groups such as Food for the Hungry, according to a Globe survey of government data. And in seeking to help such groups obtain more contracts, Bush has systematically eliminated or weakened rules designed to enforce the separation of church and state.

In Lakartinya, a simple hut built with funds from the US government is the first in the area to have a tin roof. It serves as a station for weighing babies, distributing food, teaching health classes -- and, until recently, initiating local people into the rites of Christianity, according to Food for the Hungry staff. Classes begin and end with prayers, and in some cases are followed by Christian services.

For decades, US policy has sought to avoid intermingling government programs and religious proselytizing. The aim is both to abide by the Constitution's prohibition against a state religion and to ensure that aid recipients don't forgo assistance because they don't share the religion of the provider.

Since medical programs are aimed at the most serious illnesses -- AIDS, malaria, tuberculosis -- the decision whether to seek treatment can determine life or death.

But many of those restrictions were removed by Bush in a little-noticed series of executive orders -- a policy change that cleared the way for religious groups to obtain hundreds of millions of dollars in additional government funding. It also helped change the message American aid workers bring to many corners of the world, from emphasizing religious neutrality to touting the healing powers of the Christian God.

Bush's orders altered the longstanding practice that groups preach religion in one space and run government programs in another. The administration said religious organizations can conduct services in the same space as they hand out government aid, so long as the services don't take place while the aid is being delivered. But the rule allows groups to schedule prayers immediately before or after dispensing taxpayer-funded aid.

Bush's orders also reversed longstanding rules forbidding the use of government funds to pay for employees who are required to take an oath to one religion. In addition, the president's orders allowed faith-based groups to keep religious symbols in places where they distribute taxpayer-funded aid.

And in implementing the president's orders, the administration rejected efforts to require groups to inform beneficiaries that they don't have to attend religious services to get the help they need. Instead of a requirement, groups are merely encouraged to make clear to recipients that they don't have to participate in religious activities.

Bush made some of the changes by executive order only after failing to get Congress to approve them; the bill faltered in the Senate, where moderate Republicans joined Democrats in raising concerns about breaking down the barrier between government and religion.

``I got a little frustrated in Washington because I couldn't get the bill passed," Bush told a meeting of faith-based groups in March 2004. ``Congress wouldn't act, so I signed an executive order -- that means I did it on my own."

The legality of Bush's moves is being challenged by a group advocating separation of church and state. The lawsuit, claiming both that Bush overstepped his powers and that the orders violate the Constitution, is inching its way through the federal courts.

Faith-based groups have long delivered humanitarian assistance in distant and dangerous places, marshaling an impressive array of volunteers. But Bush's initiative has put government dollars into faith-based providers in unprecedented fashion. A Globe survey of more than 52,000 awards of contracts, grants, and cooperative agreements from the US Agency for International Development -- which distributes taxpayer-funded assistance overseas -- provides the first comprehensive assessment of the impact of Bush's policies on foreign aid.

The survey of prime contractors and grantees, based on records obtained through the Freedom of Information Act, shows a sharp increase in money going to faith-based groups between fiscal 2001, the last budget of the Clinton administration, and fiscal 2005, the last year for which complete figures were available. Faith-based groups accounted for 10.5 percent of USAID dollars to nongovernmental aid organizations in fiscal 2001, and 19.9 percent in 2005.

Boost for Christians
The numbers also show that the faith-based initiative overseas is almost exclusively a Christian initiative: Only two Jewish development groups and two Muslim groups of any type got any grants or contracts between fiscal 2001 and fiscal 2005, and Christians received 98.3 percent of all such funds to religious groups from fiscal 2001 to fiscal 2005.

The prime beneficiaries have been large groups including Catholic Relief Services and evangelical organizations such as World Vision -- the former employer of Bush's longtime USAID director Andrew Natsios -- and Samaritan's Purse, which is led by evangelist Franklin Graham, the son of Billy Graham, who guided Bush to his own religious rebirth.

Food for the Hungry, which is also evangelical, received its contract to run USAID programs in Lakartinya in fiscal 1999, during the Clinton administration, and it was renewed under Bush. The group's funding jumped from $7 million in fiscal 2001 to $20 million in fiscal 2005. Bush also appointed the group's president, Benjamin Homan, to chair USAID's advisory board.

Robert Snyder, Food for the Hungry's director for Kenya, said that the group seeks to segregate religious activities from aid programs, but that Kenyans don't usually believe in the concept of church-state separation.

``In Kenya, they don't separate things out," he said.

At Food for the Hungry's outpost in Lakartinya, staff members spoke openly of how they preach about Jesus while teaching breast-feeding and nutrition. Over the seven years that the group has been operating there, it has helped convert almost the entire area to Christianity, according to it's own field workers and villagers who participate in the programs.

Sante Dokhe, a 45-year-old mother of five from the Samburu tribe, became one of the health program's first ``contact mothers." She said she used to practice a traditional African religion. Then came her US-funded classes, which impressed her by drastically lowering the infant mortality rate in the village.

``The first time that I changed my mind is when we were learning the health education and our teacher was also talking about God," Dokhe said. ``We used to go to the rivers and pour milk for the god who stays in the mountain. But I learned through our classes that that is a very tiresome god. Now we have known that you don't need to struggle to please God. Now I have learned through health education that God is everywhere."

Christian missionaries have crisscrossed the world for generations, seeking to save souls by converting people.

US foreign-aid programs, however, began after World War II for the purely secular aim of winning friends for the United States. Now, aid packages and equipment purchased with government funds are stamped with the words ``From the American People" so beneficiaries can see the fruits of US generosity.

``The point of foreign assistance is national security," said Harriet Babbitt, who was USAID's second-ranking official during the last years of the Clinton administration.

Foreign aid programs have been criticized by some conservatives as unnecessary -- frittering away money that could be used in the United States. But in the late 1990s, evangelical groups began to focus on AIDS in Africa, and conservative Christian leaders became vocal supporters of government-funded programs.

Clinton's last USAID administrator was Brady Anderson, the president's boyhood friend and an evangelical Christian. Relations between USAID and faith-based organizations were strong, according to Babbitt and Anderson.

Nonetheless, after Bush took office in 2001, he surprised many people by declaring that religious groups had been systematically discriminated against in the awarding of government contracts. His administration issued a report called ``Unlevel Playing Field" that declared that faith-based groups faced too many restrictions. ``Some government rules require faith-based providers to endure something akin to an organizational strip search," the report said.

A push for applicants
To counter the alleged discrimination against churches, Bush used federal funds to hire outreach workers to hold training sessions and attend religious conferences in hopes of getting groups to apply for funds. The initiative, Bush promised, would ``open up billions of dollars in grant money competition to faith-based charities."

USAID workers began fanning out to religious events. They tried to convince skeptics that evangelical groups could follow government guidelines while still spreading the word of the Lord.

Clydette Powell, a doctor in USAID's public-health bureau, staged a workshop on public-private partnerships in tuberculosis at an evangelical conference last year in Louisville, Ky., proclaiming, ``There are tremendous opportunities, actually, for Christians -- and for, frankly, evangelistic purposes -- within a public health strategy such as TB. "

She added: ``I think Christians, who are so much more relational in this thing, have a leg up on, you know, just the regular public system because there is interest in developing a relationship -- in fact, hopefully, a relationship that leads them to know Christ as their savior and their lord in their lives."

When key senators balked at approving Bush's faith-based initiative, he claimed that they, too, were discriminating against churches.

But James Towey, who was director of the White House Office of Faith and Community Based Initiatives from 2002 until June 2006, said the major hang-up was Bush's desire to allow religious groups to reject candidates for government-funded jobs because the workers didn't practice the group's religion.

``The hiring provision gave everybody a lot of indigestion," Towey said.

In 1965, President Lyndon Johnson signed Executive Order No. 11246, a landmark directive that required all federal contractors to consider applications ``without regard to race, color, religion, sex or national origin."

Frustrated by Congress's refusal to reconsider Johnson's policy, Bush issued his own order in 2002 specifically allowing faith-based groups to discriminate in hiring for government-funded positions.

Bush explained himself in a speech in New Orleans on Jan. 15, 2004. Standing in front of a huge cross, the president said the federal government used to tell faith-based programs to ``take the cross down from the wall" to get government money.

``The problem is, faith-based programs only conform to one set of rules, and it's bigger than government rules," Bush said.

His rule changes were encouraged by both the Catholic Church, which was already the largest faith-based recipient of government money overseas, and the National Association of Evangelicals, whose leaders say it represents 30 million people.

The Catholic US Conference of Bishops declared, ``It is more important than ever to make sure that all charities, faith-based or secular, have access to the public and private resources they need" to serve the needy.

Robert Cizik, the evangelical association's vice president for governmental affairs, said, ``Without the faith-based service providers, there is no way to begin to stem the tide of AIDS."

He said Bush's rule changes -- including the reversal of Johnson's non-discrimination order -- were needed to give smaller evangelical providers ``an equal shot at the federal pie."

Other churches protest
Yet leaders of many large Christian denominations believe it is wrong for religious groups to discriminate based on religion when using government funds. And while Bush has portrayed many restrictions intended to enforce the separation of church and state as hostile to religion, many religious leaders disagree: They say the separation of church and state has allowed religions to flourish.

Many large Protestant denominations say the administration is catering to the religious right -- particularly evangelical groups seeking funding for missions whose ultimate aim is recruiting new members.

Bishop Frank Griswold, the presiding bishop of the Episcopal Church, the faith in which Bush was raised, said he strongly opposed allowing faith-based contractors to discriminate in hiring. But the bishop said he was unable to express his concerns to Bush.

``I must say it has been very difficult for me -- and I think I can speak for the mainline churches as well -- to have any substantial engagement with the president," Griswold said. He said he has been ``shunted to one side" by the White House, which has been more interested in rewarding the religious right.

``I think it has to do with politics and power," Griswold said. ``It has a great deal to do with what Mr. Bush perceives to be his base."

Criticism also comes from representatives of the faith that Bush now observes -- the United Methodist Church.

James Winkler, general secretary of the church's General Board of Church and Society, compared Bush's claim of discrimination against faith-based organizations to his assertion that Iraq had weapons of mass destruction.

``We heard all the time that Iraq had weapons of mass destruction, and we heard all the time that there has been all this discrimination against faith-based groups," Winkler said. ``We kept on saying we haven't noticed any discrimination. The grants are there. This really came from the religious right as political payback for their support for the president."

The Southern Baptist Convention, which is the largest of several Baptist organizations, also has strong reservations about Bush's faith-based initiative, preferring to maintain a separation of church and state.

Richard Land, president of the convention's Ethics and Religious Liberty Commission, advises Southern Baptist churches not to take federal money. Noting how some British colonies in America financially supported the Anglican Church while persecuting Baptists, he said Baptists have in their ``genetic code" a dislike of such government funding.

Most Jewish groups have not aggressively sought foreign-aid contracts, some leaders said, because they do not seek to convert people, and a prime motivation for religious groups to be active overseas is to win new converts.

``Jews are not missionaries," said Ruth Messinger , president of the American Jewish World Service. ``The whole concept of proselytization is alien to us. Not only alien, almost offensive to us. Jews just don't do that."

Many Christian groups, however, acknowledge that they aim to convert new members, while denying that they proselytize.

``We would like for everyone to become a Christian, that is part of our faith as Christians," said Mark Howard, general counsel of World Vision.

Nonetheless, neither Natsios, who headed USAID from May 2001 to this year, nor Kent Hill, the assistant administrator for Global Health Programs, said they have ever received complaints of a religious contractor violating rules against proselytizing. But Natsios, at a conference last spring, acknowledged that USAID does not monitor groups for proselytizing.

Outsiders point out that members of the administration -- including the president -- sometimes seem to endorse the use of government funds for religious objectives. Speaking before religious leaders in Los Angeles on March 2, 2004, Bush discussed the difficulties of faith groups.

``I think if you ask them their biggest problem, they'd say, `Well, we need to expand, there's more souls to be saved, we need a little extra space for our rescue mission,' " he said. He then assured the groups: ``The government has got resources."

Robert Tuttle, a George Washington University law professor who has studied USAID policies, said he was dumbfounded that the agency chose not to require that aid recipients be told that they don't have to attend services: ``It is scandalous in the sense that if you really are interested in protecting the religious liberty of beneficiaries, then why not inform them of their rights?"

The government's General Accountability Office this year examined 13 federally funded faith-based organizations in the United States that offer prayer or worship. The agency concluded that four of the 13 ``did not appear to understand the requirement to separate these activities in time or location from their program services."

K. Hollyn Hollman, general counsel for the Baptist Joint Committee, which represents 14 Baptist organizations, said she is alarmed by the administration's policy that a religious group doesn't have to change its ``religious character" when distributing government aid.

Said Hollman: ``If the religious character of my organization involves evangelizing, changing your life through Christian witness, then I will be tempted to do that in a government-funded program."

The Globe's research found that in the absence of clear standards such as a prohibition on running government programs where services are conducted, religious groups feel free to ask recipients to pray, discuss their spiritual needs, and attend services.

Since many groups combine government and private funds, they feel unrestricted about proselytizing so long as they can say they were using private money. For instance, USAID has paid for tens of millions of dollars in equipment for religious hospitals, where patients learn about the Gospel while receiving care. But since the missionaries themselves are not on the government payroll, no rules apply.

Graham, whose Samaritan's Purse receives USAID funding for medical centers in Sudan and Angola, said in an interview: ``Of course you cannot proselytize with tax dollars, and rightfully so. I agree with that. But it doesn't mean that we can't build buildings, we cannot provide housing and buy bricks and mortar. The proselytizing or the preaching or the giving out of Bibles, people give us funds for those."

More Christian converts
In the dusty village of Lakartinya, Lucia Loltome, a 34-year-old nurse employed by Food for the Hungry, says proudly that she begins and ends each health class with a prayer.

Loltome became a Christian when she attended a Catholic high school. Now she is in charge of projects that involve 730 households and 1,300 children. She is proud of how she laces her lessons about typhoid, parasites, and breast-feeding with education about the Christian God.

``Before 1999, these people were not even going to church," she said. Now, all the contact mothers in the program and nearly every family in nearby villages are churchgoers, Loltome said.

A similar story is told three miles away, in an area known as Nkirmat, where Food for the Hungry began a similar project under the same USAID grant. In Nkirmat, contact mothers began learning about health education in 1999 and recently began breeding milk-producing goats. As with Lakartinya, the USAID program here has been accompanied by a wholesale conversion to Christianity, according to Antonella Kupona, the lead mother of the goat project.

``There was a church built here in 1972 but people were not going because of the traditional beliefs," she said. ``But now they are taking it up in great numbers. . . . As we go for the health education, we also learn about God."


Religious right wields clout
Secular groups losing funding amid pressure

By Michael Kranish, Globe Staff | October 9, 2006

For six decades, CARE has been a vital ally to the US government. It supplied the famed CARE packages to Europe's starving masses after World War II, and its work with the poor has been celebrated by US presidents. So the group was thrilled when it received a major contract from the Bush administration to fight AIDS in Africa and Asia.

But this time, instead of accolades came attacks. Religious conservatives contended that the $50 million contract, under which CARE was to distribute money to both secular and faith-based groups, was being guided by an organization out of touch with religious values.

Senator Rick Santorum , a Pennsylvania Republican, charged last year that CARE was ``anti-American" and ``promoted a pro-prostitution agenda." Focus on the Family, the religious group headed by James Dobson , said the agency that delivered the contract, the US Agency for International Development, was a ``liberal cancer."

The complaining paid off. CARE's $50 million contract is being phased out this year; it has been replaced with a $200 million program of grants that is targeted at faith-based providers, and overseen by USAID itself.

The pressure on CARE is emblematic of that facing many other secular groups. President Bush's faith-based initiative has not only increased funding for church groups, but also raised the expectations of the religious right, which has asserted a stronger role in setting policy.

The pattern of outcry by religious conservatives, followed by accommodation by the administration, has been replicated on numerous occasions at USAID, from personnel decisions to choices of who runs humanitarian programs overseas.

In the process, secular groups have seen an overall drop in funding. CARE's USAID dollars declined every year, from $138 million in fiscal 2001 to $96 million in fiscal 2005, the last year for which data is available, according to a Globe survey of prime contractors and grantees in the development arena.

Kristin Kalla , the CARE official overseeing its AIDS contract, said she found herself in the middle of a war over politics, religion, and money.

``There was a lot of resentment, a lot of pressure, from the religious right feeling that they supported Bush, especially for the second term, and they wanted to get paid their dues, they wanted a piece of the pie in terms of foreign assistance," Kalla said.

James Towey , the former head of the White House's faith-based office, acknowledged that he fought hard to shift international aid to faith-based groups, although he denied it was a political payback.

``The fact is [officials at USAID] tended to be left of center and they tended to be more of a secular perspective than a religious one," said Towey, who served as Bush's top faith-based official from 2002 until June 2006. ``There were pockets of extreme hostility to faith-based organizations. There were instances where people had agendas that were very clearly at odds with what President Bush had laid out as his foreign policy agenda. . . . We wanted to see the new groups have a chance."

Under pressure from Dobson, members of Congress, and Towey's office at the White House, USAID officials promoted groups favoring abstinence as the prime means of preventing AIDS. The officials gave funds to one such group despite a review panel's determination it was not suitable, and allegedly stripping money from a group that criticized the administration's emphasis on abstinence.

And USAID required groups to sign an anti-prostitution pledge despite concerns over its constitutionality. The pledge required all organizations receiving USAID money overseas to renounce prostitution, which some groups interpreted as abandoning efforts to prevent prostitutes from spreading AIDS.

The Brazilian government, which has had success in decreasing AIDS by working with prostitutes, refused to sign the pledge and lost a $40 million grant.

In an affidavit for a lawsuit over the matter, Pedro Chequer , director of Brazil's AIDS program, said his country strived to adhere to ``the established principles of the scientific method and not allow theological beliefs and dogma to interfere."

AIDS has been the Bush administration's top overseas health priority, and it consumes about half of the global health budget, much of which is overseen by USAID.

But disagreement has raged for years over how best to prevent AIDS. US policy has long supported condom use. But some religious conservatives say distributing condoms actually increases AIDS by promoting sexual activity. Others say the only sure way to stop AIDS is by teaching abstinence and faithfulness.

With faith-based groups seeking a major share of the anti-AIDS funds, the administration sought to resolve the controversy in 2003 by endorsing a three-pronged strategy of promoting abstinence, faithfulness, and, when appropriate, condoms.

Under a bill approved by Congress and signed by Bush, one third of the administration's $3 billion international AIDS prevention budget must be spent on programs promoting ``abstinence until marriage." Meanwhile, the administration was also buying hundreds of millions of condoms for distribution overseas.

But some leaders of the religious right felt that any program involving condoms is inappropriate, and they focused their anger on USAID.

The dispute erupted in public after a remark in 2002 by then-secretary of state Colin Powell, who had visited Africa and been appalled at the AIDS rate. In a television interview, Powell said that while he respected churches that are opposed to condoms, ``In my own judgment, condoms are a way to prevent infection and, therefore, I support their use."

Dobson blasted back, declaring ``Colin Powell is the secretary of state, not the secretary of health. He is talking about a subject he doesn't understand."

Raised by a Nazarene preacher, Dobson has emerged over the past three decades as one of the nation's top political leaders among religious conservatives. He is known for his strong views against gay marriage and abortion.

Dobson's organization, Focus on the Family, has played a major role in presidential politics, sending out 5 million letters, postcards, and e-mails just before the 2004 election. He is close to Bush and White House adviser Karl Rove .

The administration had hoped to avoid fights with religious conservatives by putting people in charge of USAID with strong faith-based ties: administrator Andrew Natsios and global health director Dr. Anne Peterson .

Natsios is a former Massachusetts legislator who once supervised the Big Dig and has served as vice president of World Vision, the largest evangelical recipient of USAID grants. Peterson, a physician, is an evangelical Christian and former Virginia state health commissioner who has also worked with Christian groups in Africa.

Peterson said in an interview that she assumed she would be embraced by religious conservatives.

She was wrong: Dobson's group singled her out for a series of attacks, since her global health division oversaw AIDS policy.

In September 2004, Peterson boarded a plane for Colorado on a secret and sensitive mission: to try to prevent an all-out assault by Dobson, who had vowed to use his clout with Congress to pressure USAID into giving more funds to faith-based groups.

Peterson spent the day at the Colorado Springs headquarters of Focus on the Family, culminating in a short, terse audience with Dobson himself.

``Where do you stand on condoms?" Dobson asked, according to Peterson.

Peterson replied that, as a physician, she was convinced condoms played an important role in preventing AIDS, along with abstinence and faithfulness. Dobson was displeased, she said.

``It was very clear that I did not budge him on the condom issue," Peterson said. Focus on the Family, meanwhile, prepared a briefing that was critical of Peterson, quoting her as saying that the Bush administration had doubled condom availability in developing nations.

Within months, Peterson had resigned for personal reasons, deeply bruised by the attacks.

``I had not expected to have that from the Christian community," she said. ``I had expected to find more resonance with a broader group of people to find a common ground. This is a core good thing to do, help people to stay healthy. It was disconcerting to find that when money is on the table everybody fights harder to get the piece of it."

Attacks on USAID
Dobson's group, meanwhile, turned its attention to others at USAID and the AIDS contract administered by CARE.

A private briefing on Capitol Hill in January 2005 for 50 congressional staffers prompted more than two dozen members of Congress to sign a letter demanding that more money go to faith-based groups that favored abstinence.

They complained in the letter to Natsios that government funding for faith-based groups was being ``delivered by anti-American, anti-abstinence, pro-prostitution, and pro-drug use groups."

In its printed materials for the briefing, Focus on the Family targeted a USAID official who it claimed was gay and committed to a pro-homosexual agenda.

Natsios, who left his post as USAID administrator earlier this year, said of the attack: ``It was over the top, it was outrageous."

Dobson declined to comment. The briefing was overseen by the group's chief public policy officer, Peter Brandt . In an interview, Brandt acknowledged that ``that individual should not have been targeted." But he stood by the attacks on USAID and what he called the ``condom cartel."

Peterson was replaced as head of global health by a well-known conservative evangelical leader, Kent Hill . Unlike Peterson, he had no medical degree and no prior experience in public health.

Over his long career, Hill had worked to protect evangelicals in the former Soviet Union, wrote a book stressing the importance of evangelism in the world, and ran into controversy when he became president of Eastern Nazarene College in Quincy and sought to ban non-Christians from teaching positions.

While some liberal groups expressed concern about Hill's record, he has endorsed Peterson's position on condoms, and used his credibility with evangelicals to urge religious leaders to show more civility.

``I can tell you from personal experience that all too many Christians on both the right and the left display an arrogance and self-righteousness about their views," Hill told a conference on faith and international development in Michigan last February. ``Too many Christians are judgmental, black-and-white thinkers who don't do their homework, do not nuance their positions, and on top of that are nasty and mean-spirited to those that they have a disagreement with, and in the end they undermine what they are trying to do. But what is worse, they undermine their faith."

Despite the insistence of senior USAID officials that they were not influenced by Dobson in making grant awards, many secular groups contend that the attacks have had a major impact.

They cite a case in which Natsios overruled his own review panel to provide a grant to Children's AIDS Fund, a group that highlights abstinence.

The fund has ties to both Focus on the Family and the Bush administration. It was cofounded by Shepherd and Anita Smith . Shepherd Smith has worked closely with Dobson and attended the Focus on the Family briefing that attacked USAID. Anita Smith has been the chairwoman of the Presidential Advisory Council on HIV and AIDS.

The Smiths believed that their application was just the kind being sought by the Bush administration. But USAID's technical review panel determined that the grant proposal was ``not suitable for funding." The agency has refused to release the panel's report, leaving it unclear why the proposal was considered unsuitable.

In any case, Natsios wrote a memo on Oct. 21, 2004, urging that Randall Tobias, who was then in charge of the international AIDS program, approve the funding because the group favored abstinence.

``The selection of a `non-suitable' applicant such as [Children's AIDS Fund] . . . is not inconsistent with USAID's grant-making policies," Natsios wrote. Tobias agreed, and funding was granted on Nov. 1, 2004. The grant could reach $10 million over a five-year period.

The memo raises the question of how many other ``nonsuitable" applicants have received money from USAID. Representative Henry Waxman, a California Democrat, wrote to the Bush administration that the approval ``raises questions of political cronyism."

The Smiths said in separate interviews that no political pressure was applied. They said their group is not faith-based, although it distributes money to faith-based groups.

Natsios said his decision was meant to help shore up abstinence work in Uganda, and not ``for the religious right."

But Population Services International, a secular group that failed to get the grant, worries that it lost because of its history of condom distribution.

``If they are faced with giving us a grant and someone else a grant, I think they would rather give it to the other guys because they don't want their careers to be damaged because they would be seen as fellow travelers with us," said Sally Cowal , the group's senior vice president. USAID said in response that the group still receives major contracts.

``The money is so big this is not just about ideology, it is about money," Cowal said. ``Before, the amount of money available for HIV and AIDS internationally was very small so a lot of people weren't interested. Now it is very big. Suddenly people not interested in the million dollars are interested in the billion dollars."

`A political slush fund'
Indeed, one of the biggest sources of money to faith-based groups comes from the Bush administration's AIDS initiative, the President's Emergency Plan for AIDS Relief (PEPFAR), with much of the money having been funneled through USAID.

The total PEPFAR budget is $15 billion over five years, including $3 billion for prevention. Of that amount, about $1 billion must go for ``abstinence-until-marriage" programs.

Some of those who have lost funding under the Bush administration, however, say the huge abstinence budget has been used as a political payout to faith-based supporters of administration policies.

For example, a nonprofit organization called Advocates for Youth, which focuses on AIDS and teen pregnancy, says it lost an $800,000 contract for AIDS prevention among youth in South Africa, Nigeria, and Botswana because it had been critical of the administration's emphasis on abstinence.

``At times it turns into a political slush fund for organizations that are ideologically aligned with the administration rather than public health organizations with a proven track record," said James Wagoner, president of Advocates for Youth. A PEPFAR spokesman said the group's grant expired.

Dr. Mark Dybul , who oversees PEPFAR, said funding decisions are all made on merit . But he added that he considers faith-based groups to be crucial partners: ``Our goal is not the recruitment of faith-based organizations . . . [but] to me, as the coordinator, you cannot achieve those goals without faith- and community-based organizations."

Dybul stressed that he supports Bush's strategy of using abstinence, faithfulness, and condoms to fight AIDS. But he also said that until recently there was too much reliance on condoms.

``Just go to an international meeting and mention the words `abstinence and fidelity,' " Dybul said. ``I've sat in rooms where people snicker."

Kalla, who administered the program of AIDS grants to faith-based and community-based groups for CARE, said the pressure to give money to religious groups was intense.

She cited an example in which she determined that a small faith-based group favored by senior administration officials was not qualified to manage hundreds of thousands of dollars. Kalla said that she was roundly criticized by the officials, and that the administration found another source of money for the group.

Kalla said CARE made special efforts to fund faith-based groups, but she said administration officials sometimes criticized the grants that went to Muslim and Jewish groups.

``We were told repeatedly by staff at USAID directly in meetings that these were not the `right types' of faith-based organizations that the White House faith-based office was looking for," Kalla said. In an effort to placate USAID, she said, CARE awarded a $100,000 grant to Samaritan's Purse, a group run by Bush's friend, Rev. Franklin Graham, for work in Mozambique. She said USAID informed her it was the right type of faith-based group.

The USAID official who oversaw the CARE program said he did not pressure Kalla to favor conservative groups. And Natsios and Hill said that all groups are treated equally in the funding process.

Nonetheless, the pressure on USAID from Christian groups has raised persistent questions about whether Jewish and Muslim organizations are being overshadowed.

The Globe survey of prime contractors and grantees indicated that 98.3 percent of funds to faith-based groups went to Christian-led organizations.

Eugene Lin , a former employee of the office of faith-based programs at USAID, said the office catered mostly to evangelical Christians. He calculated that of 167 organizations invited to discuss potential grants during a 15-month period ending in September 2004, only five were non-Christian.

``I was fairly outspoken in the office, saying it is really unfair we never invite Jewish or Muslim groups to our office, everyone is Christian," Lin said. ``There is no balance whatsoever."

Lin said that he was told by the acting director of the office, Linda Shovlain , that she wanted to have what she described as a ``Come to Jesus" meeting to discuss his work. Lin said he felt intimidated because Shovlain had a 2-foot high crucifix over a conference table in her office.

Lin eventually was fired, and filed a religious-discrimination complaint.

In a deposition, Shovlain said her ``Come to Jesus" remark was misunderstood.

``One day, after I had had to exercise tremendous oversight over [Lin], I told him jokingly that if things continued as they had been that we would have to have a `Come-to-Jesus' meeting, and jokingly added that if we could not come to resolution on his performance I would fire him," Shovlain said in the deposition. ``I very quickly saw he thought this phrase `Come to Jesus' meeting had a religious connotation, and I explained to him that this phrase was an expression for having a meeting where we discussed plainly what needs to change and find resolution."

Shovlain added: ``If I had known he was so sensitive about religion, I wouldn't have used the term. . . . I didn't know until recently he was Jewish or so sensitive about religion."

A USAID panel dismissed Lin's complaint in July. He has filed an appeal.

The panel endorsed Shovlain's right to display the crucifix, quoting from a 1997 federal regulation that a federal employee may display religious art as long as it does not create the impression that the government is ``favoring or disfavoring a particular religion."

Fighting back on pledge
A centerpiece of the religious right's agenda for USAID is a law passed by Congress and signed by Bush in 2003 that requires any US-based group receiving anti-AIDS funds to adopt a policy against prostitution.

The law says funding cannot be given to any group ``that does not have a policy explicitly opposing prostitution and sex trafficking." Supporters said they hoped the legislation would ``eradicate" prostitution and thus curtail the spread of AIDS.

While few, if any, aid groups support prostitution, many expressed concern that the US policy was so broad -- and applied even to their private funds -- that it would obstruct their outreach to sex workers who are at high risk of transmitting the AIDS virus.

In some countries, half of all prostitutes are infected with the AIDS virus, according to congressional testimony. As a result, USAID's leaders originally were sympathetic to groups that resisted the anti-prostitution pledge.

The issue seemed to be resolved when the Justice Department advised USAID that the law was unconstitutional on the grounds that it violated free speech.

But the decision set off a firestorm of protest from the religious right and its allies in Congress, after which Bush's Justice Department reversed itself.

When USAID then started requiring the pledge, some major grant recipients refused to take it -- and suffered.

The Brazilian government, which lost $40 million, said the pledge would undercut one of its most successful anti-AIDS strategies, persuading sex workers to use condoms or other measures to stop spreading the disease.

Chequer, the country's AIDS director, said its work with prostitutes is a major reason why Brazil's infection rate among young adults is only 1 percent.

``We view sex workers as essential partners in our HIV prevention efforts," Chequer said.

The US government disputed that the pledge would suspend the Brazilian AIDS program, but other funding recipients interpreted the pledge the same way as the Brazilians.

American Jewish World Service, one of a handful of non-Christian faith-based groups to get US funds, received a single subgrant of $60,000 for AIDS work in Kenya, provided through the CARE program. The organization reluctantly agreed to sign the anti-prostitution pledge but quickly had second thoughts. The organization tries to stop the spread of AIDS by providing education opportunities for children of prostitutes, which can help mothers leave the brothels.

Julia Greenberg , the group's international aid director, said she believes the anti-prostitution pledge was designed to make grants more accessible to conservative Christian groups. She said her organization has not sought more funds ``because of the politics involved."

Some organizations that refused to sign the pledge have fought back. A company called DKT International says it lost US funds for a $60,000 AIDS program in Vietnam. DKT filed suit against the federal government, saying the pledge violated its First Amendment rights.

A similar lawsuit was brought against USAID by several other groups, including Pathfinder International, a Boston-based humanitarian group, and an aid group founded by billionaire George Soros.

To some conservative faith-based leaders, however, the plaintiffs in both cases are symbolic of what's wrong with US policy. Soros financed groups opposing Bush's re election. DKT is run by Philip D. Harvey, who operates a large mail-order pornography business that is separate from his anti-AIDS organization.

But in both cases, judges sided with the plaintiffs, issuing restraining orders that prohibited USAID from enforcing the anti-prostitution pledge.

Moreover, a judge in the Soros case declared that the Bush administration had altered its stance on the pledge due to political pressure.

US District Judge Victor Marrero noted that Senator Tom Coburn , an Oklahoma Republican, had written a May 19, 2005, letter to Bush blasting USAID for funding programs for prostitutes to attend ``parties and games."

The sponsor of the program mentioned in the letter said that it was a bingo-style program designed to educate prostitutes about AIDS.

The judge found that the pressure had an immediate effect: By June 2005, the Justice Department had reversed its position on the constitutionality of the pledge, and USAID was requiring groups to sign it.

``This shift in position coincided with pressure exerted upon USAID and the President," Marrero wrote.

Enforcing the pledge would do ``irreparable harm" to the aid groups' rights to free speech, Marrero said.

The Bush administration appealed the decision in August.

Globe Correspondent Kevin Baron contributed to this report.

Part 3: THE MUSLIM WORLD | EXPORTING FAITH: Together, but worlds apart

Christian aid groups raise suspicion in strongholds of Islam
source: Boston Globe, October 10, 2006

SAHIWAL, Pakistan -- The X-ray machine at the Christian Hospital here is emblazoned with a USAID sticker to promote the US government's donation of top-of-the-line medical equipment. So is the blood bank refrigerator, the auditorium for medical lectures, and the radiology computer -- all sparkling new messages of help for the people of Pakistan, a crucial ally in the war on terrorism.

With a cleanliness and order that are in stark contrast to the crowded and filthy municipal hospital across town, the Christian Hospital, run by the Christian group World Witness with US government assistance, seems an easy choice for the nearly all-Muslim community it offers to serve. The public hospital is understaffed and underequipped, with patients slumped in dirty hallways and anxious parents holding crying, sickly babies awaiting a doctor's attention.

But like many Christian facilities in this Muslim nation, the Christian Hospital is an entity apart. It cares for 14,000 to 15,000 patients a year, compared with 1 million at the municipal hospital, and the neediest patients say they can't afford the few dollars for admission and a few blood tests.

Only a dozen or so patients sat in the waiting room during a recent visit, their traditional Muslim dress looking out of place in a facility with tile crosses in the walls and a New England-style chapel in the courtyard.

A rifle-carrying guard patrols the entrance -- a grim sign of the danger Christian groups face in a nation whose citizens believe their Muslim faith and brethren around the world are under attack by the largely Christian West.

Christian groups are running health care, education, and disaster relief in many Muslim nations, and USAID has awarded about $53 million from 2001-05 to fund projects by Christians in Pakistan, Indonesia, and Afghanistan alone. Both the aid organizations and the US government hope the projects will sow good will in a region growing increasingly wary of the West.

But the war in Iraq and the detention of Muslims at Guantanamo Bay have greatly angered Muslims, and residents are finding it hard to separate the policies they vehemently oppose from the activities of Christian aid groups, said local Islamic leaders.

``People hate America as a whole. People in general think the West, and Bush especially, have a double standard for Muslims. They are killing Muslims," said Ameer-Ul-Azim , secretary of the Jama'at-e-Islami party in Lahore. ``It can come to the point where it can affect the relationship between the Muslim community and the Christian community."

Fighting terror with Christ While Christian Hospital officials insist they are there to heal, not to proselytize, World Witness's own literature suggests that part of its mission is to spread Christianity.

A brochure for the hospital says ``The Jesus Film" ``is shown to all patients," and goes on to say that ``the hospital and staff feel that through Christ, terrorism will be eliminated in this part of the world," a phrase that offended Muslim leaders who say Islam is about peace, and not violence.

``If I am given such a message, I ask, `Why are you spreading hatred among human beings? What is your agenda?' " said Abdul Rauf Farooqi , a Lahore-based member of the board of the National Religious Schools Council.

Christian groups say that view is mistaken. The Rev. Frank van Dalen , World Witness's executive director, said ``The Jesus Film" is only shown in the waiting room, and not constantly. He winced when he was shown the brochure's reference to eliminating terrorism through Christ.

``That's a dumb thing to say. It doesn't work that way," he said.

Still, critics say, the Bush administration's special efforts to reach out to faith-based providers, the vast majority of whom are Christian, almost can't help but raise suspicions in Muslim countries.

``I think it's important to step back and look at the wisdom of putting faith-based components into a program like this that is operating in a Muslim nation. The last thing we want to do is create the impression in the Muslim world that the US government is funding groups that seek to convert Muslims to Christianity," said Rob Boston , spokesman for Americans United for the Separation of Church and State. ``When USAID gives money to religious groups that put Christian symbols in their facilities, and leave evangelical tracts lying around, it's hard to draw any other conclusion [than] that it looks like proselytizing."

Defenders of the Christian groups say religion shouldn't come into play. ``As long as it effectively delivers the good the government offers -- such as medicine -- the organization should not be discriminated against simply because it is motivated by faith," said Ryan Messmore , a religion specialist with the Heritage Foundation.

But far from discriminating, USAID has become a growing source of funds for Christian groups in the Muslim world. USAID spent $57 million from 2001-2005 (out of a total of $390 million to nongovernmental agencies) to fund almost a dozen projects run by faith-based organizations in Pakistan, Indonesia, and Afghanistan, according to records obtained by the Freedom of Information Act. Only 5 percent of that sum went to a Muslim group, the Aga Khan Foundation of the USA, which was given approximately $3.5 million for projects in Afghanistan and Pakistan.

And even that amount is well below what the Aga Khan Foundation received under the Clinton administration, including $4.9 million in fiscal 2000 alone.

In the wake of the devastating 2004 tsunami, no Muslim organization has been awarded a prime USAID award for relief work in Indonesia -- a sore spot among Muslim groups that want to help there.

In fact, of the nearly 160 faith-based organizations that have received prime contracts from USAID in the past five years only two are Muslim.

Mark Ward, USAID's senior deputy assistant administrator for Asia/Near East, speculated that Muslim groups may be disadvantaged because larger, more established groups have mastered the grant-application process.

``We like the diversity it shows in a program if we have a group that is tied to Islam," Ward said, adding that Islamic groups are encouraged to apply.

Bush's faith-based initiative is geared to help faith-based groups navigate the application process. But it has worked mostly for Christian groups, whose share of USAID funding has roughly doubled under Bush and accounts for 98.3 percent of all money to faith-based groups.

For its part, the Pakistani government says it has no problems with Christian aid groups, as long as they do not break laws against blasphemy. But the tension between what is perceived as the largely Christian West and the Muslim East is evident.

``I have never had a problem with any Christian organizations. Charity work has no religion," said Tasmin Aslam , the Pakistani Foreign Ministry spokeswoman. ``It's certainly not like Muslim organizations in the West, who are seeing that they are perceived that if they are collecting money they must be doing it for terrorist purposes."

Christian relief officials say they understand the rules, and know they probably could not survive -- and might even be in physical danger -- if they engaged in proselytizing.

``If the community ever was against us, we would have been out long ago. They could kick us out tomorrow," said van Dalen, a former missionary who has spent 12 years in Pakistan and has mastered the very difficult language of Urdu to communicate directly with locals.

But since 9/11 and the Iraq war, religion has been melded with politics in Pakistan, religious and political officials say, and the Christian groups have been caught up in a virulent anti-American sentiment.

Local newspapers are filled with articles critical of Bush's Middle East policy. A large billboard in Lahore displays a fearsome caricature of the American president with fangs, above a depiction of a crying infant and a man who appears to have been wounded in a bombing. ``Who's Next?" the billboard slogan asks.

Even a visit by actress Angelina Jolie, who has done humanitarian work around the world in her capacity as a special UN envoy, was received with some trepidation because she is American.

Linking US, Christianity Christians operating in the Muslim world must also contend with local worries that they are only there to spread their religion -- a concern that reflects fears that Western foreign policy has an anti-Islam agenda.

Since Islam is linked with government in Muslim countries, Muslims often have difficulty seeing that religion is officially separate from government in the United States, Boston said. Any activity that could be seen as proselytizing becomes associated with the US government.

Faith-based groups receiving USAID grants may not tie assistance to religious participation, but the symbols and religious tracts are enough to provoke discomfort in many Muslims, who are deeply resistant to conversion.

The tension became lethal for The Christian Hospital Taxila. The facility, located next to a mosque in the northern Pakistan town of Taxila, was attacked in 2002 by Muslim extremists, who killed four nurses and damaged the hospital's chapel. Now, the hospital, which does not receive US funds, is protected by a thick concrete wall and armed security.

Another Christian group, Evangelistic International Ministries, declined even to say where it is operating in Pakistan, citing security concerns. The group, which received a $291,000 USAID grant, but for operations outside Pakistan, has been involved in helping earthquake victims, said the group's president of project development, Michael Goodwin . The group's website states that it has handed out 700 Bibles in Pakistan.

The Christian Hospital in Sahiwal evacuated its staff after Sept. 11, 2001, and doctors have been trickling back since then. Until recently, local police protected the century-old hospital, fearful that the Western staff might be targeted, van Dalen said.

Workers at Christian facilities say they must be careful to accommodate Muslim sensibilities. At Sahiwal hospital, for example, men and women stand in separate lines to collect prescriptions, and are housed in different parts of the hospital.

Another Christian group operating in Muslim countries, World Vision, said it goes so far as to ban its Muslim staff from attending Christian prayer meetings in Pakistan and Afghanistan to make sure no one thinks the group is proselytizing, said spokeswoman Dineen Tupa . World Vision receives USAID funding, but not for projects in Pakistan and Afghanistan.

While the organization's stated mission includes spreading the love of God and Jesus, ``We're not here as evangelicals. For our staff's protection, we don't do it. For our Muslim staff, it could get them killed," said Tupa, World Vision's sub-regional director for Central Asia.

But with tensions simmering between Muslims and the West, local Muslims say they are growing suspicious of what they see as obvious shows of Christianity .

At the Taxila hospital, the walls are dotted with Bible verses, and a book room features tomes on Christianity. Muslim leaders in the town said they are offended by reports that the Christian hospital is handing out religious books at the door.

``Of course, we want them to stop this," said Amir Shahzad , head of the mosque that is right next door to the walled Christian hospital. ``This is a Muslim country. Our feelings are hurt by this."

The Taxila hospital's administrator, Dr. Joseph Lall, said the staff does not proselytize. ``If you don't want to get hit on the head, you don't do it," he said.

In Sahiwal, local mullahs said someone was passing out Christian leaflets near the hospital on Pakistani Independence Day in August; van Dalen said hospital staff had nothing to do with it.

That distinction is lost on some Muslim leaders.

``In general, we feel the NGO [nongovernmental organization] sector is directly trying to spread Christianity in this area," said Qari Tahir Rashidi , a mullah in Sahiwal. And while it is only a few ``fanatics" that have committed deadly attacks on foreign Christians in recent years, moderate Pakistanis are becoming more suspicious of all things Western, he said.

Some urge secular focus Given the mistrust, some critics wonder why the US government is aiding Christian groups in Muslim nations instead of secular organizations that might draw less controversy.

``The problem with faith-based funding, whether domestically or internationally, is that their orientation is often proselytizing. We may be funding them in one area, but they are using other funds for proselytizing," said California Representative Henry Waxman, senior Democrat on the House Government Reform Committee, which does oversight and investigations.

``If it's a Christian hospital in a Christian area, then I think that would be helpful [to the United States] for the public to see us supporting it. But if it's a Christian hospital in a Muslim area and we're not helping the Muslim charities, it's a bit of an insult," Waxman said.

Still, some Muslims do patronize Christian hospitals, saying the quality of care is more important than any religious differences.

Mukhtiar Bibi , a 19-year-old who is learning the Koran by heart, appeared embarrassed when asked why he brought a family member to the Taxila Christian Hospital. ``We have more faith in the care at this hospital," he said.

Patients at the Sahiwal facility said they had heard positive things about the hospital; Alir Rezwan , 34, said he traveled a long distance and spent 300 rupees -- about $7 -- to bring his wife to Sahiwal for treatment of arthritis. ``I have been to many different doctors for this, maybe here, she will be cured," he said.

But for all the good intentions of the hospital staff, the gleaming new equipment paid for by USAID is not benefiting most of the people who need it in the community. One of the radiology machines is not used to its full capacity, a hospital administrator said, because the facility doesn't have a specialist who knows how to use it.

In addition, the cost -- while stunningly inexpensive by Western standards -- is still too much for destitute Pakistanis who desperately need medical care. ``Sure, if it were two rupees, I would go" to the Christian Hospital, said Rani Nazeer , 30, as she awaited her turn at the municipal hospital. Two rupees -- the price of registering at the public hospital -- is less than four cents; a Muslim patient at the Christian Hospital showed that his bill for a blood test was 130 rupees, less than three dollars.

Van Dalen said the Christian hospital does not operate for profit, keeping its prices as low as it can. Further, he said, accident victims are required by law to go to the public hospital, meaning World Witness's doctors can't treat them.

For those who do come to the Christian Hospital, van Dalen promises top-quality care and an environment ``very sensitive" to Muslim customs.

``We have to be very careful that we live out our faith more than we talk about it," van Dalen said. ``I want Muslims to become Christians. But I can't make someone become a Christian. Only God can do that."

Globe correspondent Kevin Baron contributed to this report

PART 4: MISSIONARIES IN TRAINING | EXPORTING FAITH: Healing the body to reach the soul

Evangelicals add converts through medical trips
source: Boston Globe, October 11, 2006

LOUISVILLE, Ky. -- Dr. David Dageforde's life changed in a makeshift medical clinic in remote Ethiopia as he stared into the yellow, sunken eyes of a man with advanced liver disease.

The man's family had carried him three hours on a stretcher fashioned from tree limbs and a blanket. Dageforde's years in a lucrative cardiologist practice in Louisville had taught him that this man would die, 11 hours from the nearest hospital.

Amid the grieving family, a missionary began praying, talking of eternal life.

``Seeing their eyes, their faces, their look and understanding" revealed the awesome power of connecting healthcare with spirituality, Dageforde said.

It's a revelation that hundreds of thousands of other evangelical Christians have experienced, and it is changing America's foreign policy. Pressure from medical missionaries helped focus the Bush administration on AIDS in Africa and on genocide in Sudan. It is also one of the forces behind President Bush's faith-based initiative -- his effort to give religiously inspired groups more federal funds to provide services such as healthcare, education, and food to people in the Third World.

Dageforde, who founded an annual conference on medical missions that attracts thousands of doctors, nurses, and untrained volunteers, says that while spiritual revelations transformed his medical career, medicine is also changing the way missionaries convert souls.

``To give a Gospel message without caring for the people doesn't work," he said. ``Now, we try to care for the whole person -- physically, mentally, spiritually."

Drawing lessons from Jesus' life and from near-mythic role models like Dr. David Livingstone , medical missions are blossoming in popularity. Packing pills and syringes alongside their Bibles, an estimated 150,000 American Christians took medical mission trips last year of anywhere from a few days to several months, joining the approximately 2,000 medical professionals who are full-time missionaries.

More than 100 US-based organizations -- mainly nonprofits that are loosely affiliated with particular evangelical churches -- help supply or organize medical missions, according to the most recent Mission Handbook published by the Billy Graham Center at Wheaton College in Illinois. Countless churches sponsor their own trips, typically with volunteers paying their own way.

By presenting healing as the product of the word of Christ, the movement joins proselytizing and the practice of medicine to a degree that troubles some medical ethicists. Critics argue that offering basic medical treatments as the work of Christ is a manipulative way to gain new Christians.

But to those who serve in medical missions, the twin goals of physical and spiritual treatment are impossible to separate.

``Doctors treat, but God heals," said Dr. Sam Molind , a facial surgeon who has been on more than 100 short-term medical missions and now directs Global Health Outreach, a not-for-profit that organizes such trips.

``There is a marriage in the ministry of Christ between health wellness and accepting him as Lord and Savior," Molind continued. ``To me, that's an inseparable thing. Faith and medicine are related. There is a healing -- a health and a wellness -- that comes from your faith."

Though many groups eschew federal funds for fear of detracting from their religious goals, the world of medical missions is so intertwined that federal dollars are sometimes involved in missions even if the sponsor does not receive government money.

Medical suppliers and mission hospitals are among the largest recipients of federal aid among faith-based groups, so even if missionaries themselves do not get funding, they might at clinics outfitted by the US Agency for International Development.

The Bush administration's efforts to clear obstacles to faith-based groups receiving foreign-aid contracts have expanded the reach of medical missions, as the missionaries themselves have changed the image of the United States overseas.

The Rev. Franklin Graham , the president of Samaritan's Purse -- which received federal assistance for medical centers in Angola and Sudan -- estimated in a statement on his website last year that such hospitals bring ``thousands of people each year to salvation in Jesus Christ."

Said Graham: ``As God uses the medical ministry of Samaritan's Purse to ease pain and suffering, He also enables us to introduce multitudes to the Great Physician."

Inspiration for missionaries
When Dageforde saw a flier at his Southeast Christian Church in Louisville advertising a medical missionary trip to Ethiopia in 1994, he was interested in it as an adventure, on par with his scaling of Mount Rainier and Kilimanjaro.

But he returned with a renewed sense of purpose. He sold his Porsche 944 and bought a 1984 Chevy pickup. He resigned as managing partner of his heart practice and scaled back to part time, to allow more time for missionary work.

In addition to organizing the annual Global Missions Health Conference at his Louisville church, he's been on 17 mission trips -- to India, China, Gabon, Afghanistan, Guatemala, and five more times to Ethiopia. He often prays with his patients after administering treatment.

``It's easy to go to church on Sunday and be a good person during the week, but I saw the Gospel lived," Dageforde said.

Now, he's become a hero to many medical missionaries, alongside others who cast a larger-than-life aura. Their stories have become powerful religious allegories for those who seek to follow in their footsteps.

Don Richardson , who lived among indigenous peoples and now teaches classes for would-be missionaries, tells a story about a young tribesman and his ear.

A wild pig had opened a gash so deep that the ear was hanging by its lobe. Given the sparse supplies Richardson and his wife, Carol, had in what is now Papua, Indonesia, reattachment would be a challenge.

He also knew that, in keeping with Auyu tribal custom, he and his wife could be killed if they were believed to have contributed to the man's death.

``It might turn gangrenous and the poison would go to his brain and kill him," Richardson recalled. ``We had to be very careful."

Yet the man insisted that he'd rather die than lose his ear. So Richardson held a generator-powered lamp while Carol, a nurse, sewed the ear back on.

The operation worked -- and the Richardsons were on their way to converting another Christian. It was a pattern repeated countless times over the 13 years they lived among remote tribes. Richardson estimated that he and his wife saved, on average, the life of one person a day; receiving such care ``softened hearts," he said, and led whole villages to convert to Christianity.

Similarly dramatic stories of conversions made possible by seemingly miraculous medical care have drawn innumerable people of faith to mission work.

Beginning with Saint Paul of Tarsus, innumerable Christians have devoted themselves to answering Old and New Testament commands to spread the word of God.

But despite biblical stories of Jesus healing physical ailments, the concept of adding healthcare to missions is less than two centuries old. Before that, missionaries had neither the ability nor the desire to heal those they sought to convert, believing that their main focus should be on spiritual needs, said Arun W. Jones , who teaches mission history at Austin Presbyterian Theological Seminary.

Doctors first joined in missions in the early 19th century, primarily to care for the missionaries who were being exposed to unfamiliar diseases and conditions. By the mid-1800s, however, Livingstone and other pioneers were using improved medical treatments to break down barriers to conversion, presenting the message of Christ as part of their care.

``By end of the 19th century, you had a change in rhetoric," Jones said. ``There's a sense that Western medicine is not simply a new and helpful technology, but Western medicine is one of the signs of what Christianity can do."

With the support of mainline Protestant denominations that helped build mission hospitals, medical missions grew dramatically through the first half of the 20th century, creating what some called a ``golden age" for medical missionaries. By 1925, the World Missionary Atlas counted 1,157 missionary doctors from Europe and North America.

After World War II, as medical costs skyrocketed, mainline denominations dropped some of their support for medical missions. But the drop-off has been more than offset by the nonprofit groups and their legions of volunteers.

``We've basically won the argument: Faithful Christians are supposed to care about the whole person," said Ronald J. Sider , a professor of theology at Palmer Theological Seminary in Pennsylvania. ``Persons are not just souls, or not just complex material machines. They're some profound mix of spiritual and material. The only way to get the most effective transformation is to work at every aspect of the person."

Medical missionaries report stunning successes in making conversions. Dr. David Stevens , who spent 11 years as a missionary in Kenya, said his hospital converted 5,000 per year on average, while tending to people who had no other access to healthcare.

The hospital held chapel services every morning and suspended patient care during that time to emphasize religion. They prayed with patients and taught the Gospel. Most powerfully, Stevens said, the doctors served as living examples of the power of Christ's love.

``The message of our religious beliefs was magnified by the care we had for patients," said Stevens, executive director of the Christian Medical Association. ``Nothing speaks louder than sacrifice."

Such sacrifice can have a profound impact on the practitioners as well as the recipients of care. Susan Harris , a registered nurse who came to a missionary training course in Louisville to prepare for an upcoming mission to Afghanistan, said she expects to witness divinely directed ``healings," strengthening her own faith and helping spread the message of Christ.

``They'll see that God is real, that he heals people, and that's a huge open door," said Harris, 24, of Charlestown, Ind.

Missionary doctors generally insist that they never refuse treatment to anyone who is not receptive to their religious messages. Yet bringing medical care under the umbrella of religion inevitably raises questions of propriety -- particularly if the people being served have no other access to modern medicine, said Richard P. Sloan , a professor of behavioral medicine at Columbia University Medical Center.

``Who could object to medical professionals taking time out of their practices to go to impoverished areas around the world to deliver free care?" Sloan said. ``But if the delivery of medical care is contingent on some kind of manipulative or coercive religious communication, that's another story. When you're talking about people with no other sources of medical care, who are desperately ill, this kind of thing can be outright manipulative."

With cures, a lesson

Yet far from separating the medical from the spiritual, many missionary groups strive to intertwine the two to the point that they are indivisible.

At Medical Ambassadors International, one of the leading groups in medical missions, missionaries are trained in a strategy called ``Community Health Evangelism," which aims to fully integrate healthcare with Scriptures.

Missionaries learn to present malaria, for instance, first in medical terms -- what causes the disease, how it's spread by mosquitoes, and how cyclical symptoms make some people wrongly believe they are cured. Missionaries administer vaccines and treatments and also teach a scriptural parallel from the Bible's First Epistle of Peter: ``Your enemy, the devil, prowls around like a roaring lion looking for someone to devour. Resist him, standing firm in the faith."

Clean water is presented as Christ's ``living water," from the Gospel of John. Missionaries also quote biblical passages to impress the importance of clean latrines and basic agriculture. The aim is changing the behavior that causes disease, not just treating diseases, thus providing a path to healthy living as well as salvation, said Henri Haber , the group's director of mission advancement.

``We don't ask people to convert. We ask them to follow Jesus," he said.

Perhaps nowhere is the approach more evident than with HIV/AIDS. Some church groups used to shy away from AIDS patients, in large part because of the behaviors associated with the disease.

But Dr. Florence Muindi , a veteran missionary who has worked extensively in Kenya, Ethiopia, and Sudan, said she has detected ``a major shift" by religious organizations in recent years. As AIDS has exploded across Africa, missionary doctors have responded as if they have a ``special obligation," since they perceive so many sufferers to be in need of both medical help and spiritual assistance.

``The church is the custodian of the true solution to AIDS," Muindi said, referring to the behavioral changes that can stop the disease's spread. ``If there's anything positive about the pandemic, it's the way people are more receptive to the Gospel when they have a terminal illness. The church has the mandate to deal with such things, and they have the message to bring about a change in behavior that is lasting."

Spreading the Gospel is a task medical missionaries approach with a sense of urgency; many evangelicals believe Christ represents the only path to salvation and see healthcare as a way to reach more hearts. David Sills , a professor at Southern Baptist Theological Seminary who has traveled on missions in Ecuador, said the knowledge that so many people have yet to be reached serves as his daily inspiration.

``Fifty thousand people die every day never having been exposed to Christ," Sills said. ``What motivates me and gets me up every day is that if we don't reach these people, they're going to hell for all eternity."

Medical missions are spreading at the same time that evangelicals have grown more aggressive in seeking to convert Muslims and combat the influence of Islam, a trend that has quickened in the years since the Sept. 11, 2001, terrorist attacks. Islam, like Christianity, puts an emphasis on proselytizing, and many areas where Christian missions are active have significant Muslim presences.

Richardson counsels missionaries-in-training to learn enough about Islam to persuade Muslims to convert. ``I see world history as culminating in a to-the-finish-line test of wills between the two leading religions: Christianity and Islam," he said.

Not all missionaries judge their effectiveness by the numbers. Some veteran medical missionaries say the days of sudden cures bringing instant conversions are largely over, since so much of the world now at least knows of modern medicine even if so many lack access to it.

John Verburg , a Laramie, Wyo., resident who has led more than three dozen mission trips and has been on short-term trips for 30 years, recalled a visit he made to Honduras in August. The team of 12 -- including a doctor, two dentists, and a nurse -- saw nearly 900 people in eight days.

They treated burn wounds and rotten teeth and even high blood pressure, yet they did not convert anyone. But as his team was leaving, he saw a group of children drawing pictures of the nativity scene, and of Jesus walking on water. The children probably didn't grasp the spiritual messages, but the next team of missionaries in the area will have something to build on, he said.

``In terms of healthcare, we're not making a permanent difference," Verburg said. ``Where we make a difference -- eternally, I think -- is by coming down, everybody knows that we came down as Christians.

``I don't see the instantaneous, quid-pro-quo kind of thing with conversions," he continued. ``But I do believe, since we go as Christians, and we come being known as Christians, what we do is interpreted for the glory of the kingdom for many, many years after we leave."

Globe correspondent Kevin Baron contributed to this report

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