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Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop (2018)

Chapter: 3 Leveraging Resources to Advance Equity in Rural Areas

« Previous: 2 Potential Challenges and Opportunities in Rural Communities
Suggested Citation:"3 Leveraging Resources to Advance Equity in Rural Areas." National Academies of Sciences, Engineering, and Medicine. 2018. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24967.
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3

Leveraging Resources to Advance Equity in Rural Areas

Foundations are part of a “third sector,” beyond government and industry, that seeks to leverage resources to achieve the missions of its organizations. At the workshop, three leaders of local and regional foundations discussed the particular challenges of securing and applying resources to build on the community’s strengths in rural areas.

Suggested Citation:"3 Leveraging Resources to Advance Equity in Rural Areas." National Academies of Sciences, Engineering, and Medicine. 2018. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24967.
×

THE BLACK BELT COMMUNITY FOUNDATION

The Black Belt Community Foundation serves 12 rural counties in Alabama’s Black Belt, a name referring to the band of rich black soils stretching across Alabama that is well suited for growing cotton. The Black Belt is one of the most pluralistic areas in the state, said the foundation’s executive director, Felecia Lucky. It is diverse in race, age, political ideology, and educational attainment. The Black Belt Community Foundation seeks to enhance this dynamic region by investing in programs and organizations that aim to bring communities together.1

Many African Americans within the Black Belt still reside in the areas where their slave ancestors once lived. The legacies of slavery have had and continue to have a detrimental effect on the lives of those living in former slave-holding areas, said Lucky.

The foundation originated when leaders and organizers in the region came together in 2002 and noticed that many philanthropic dollars were coming into the state of Alabama, but very few were reaching the 12 counties that needed them most. Instead, change was being funded by the people who lived in those communities, said Lucky. The foundation was established as a way of forging a collective stream of giving from the community and other sources so the people of the Black Belt can continually lift themselves up by “taking what we have to make what we need,” she said. (This phrase gradually became a theme of the entire workshop.) It strives to create a flow of resources from the community, to the community, and by the community, coupling resources that currently exist in the community with resources from outside the community to create positive change. The foundation’s vision statement says it this way:

We believe that every member of our community has a vested interest in seeing our vision—a transformed Black Belt, where all of our residents contribute to healthy communities and reap the benefits of our shared gifts and a productive regional economy—realized.

The foundation’s first task was to explain to the people it served what a community foundation is and does. Lucky listed the foundation’s values:

  • We place the community as our highest priority.
  • We value the strengths of a multifaceted community where economic, racial, and social justice are universally practiced.
  • We value relationships and connections that build trust.

___________________

1 The foundation does not serve Montgomery County, in which the city of Montgomery lies, because it has a separate community foundation.

Suggested Citation:"3 Leveraging Resources to Advance Equity in Rural Areas." National Academies of Sciences, Engineering, and Medicine. 2018. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24967.
×
  • We value integrity, inclusion, and transparency in both grant making and stewardship of resources.
  • We value community leadership in acquiring and sharing knowledge.

“Those sound like buzzwords, but they are really words that we live by,” said Lucky.

Its first grant-making cycle was in 2005, with a particular focus on nonprofit organizations that could help transform aspects of the community. The Black Belt Arts Initiative Grants Program, for example, provides funding to support nonprofits that promote the arts. The foundation’s Community Associate Program (which is its signature grassroots leadership development program) has provided training opportunities for over 120 individuals throughout the region. The foundation provides capacity building workshops that cover governance, financial administration, volunteer management, and other tailored trainings to support grantees. Its community grants program provides support for a wide variety of projects, including volunteer fire departments and tutorial programs.

As a specific example, Lucky described Project United, which is a partnership between the foundation’s community associates and the University of Alabama’s School of Medicine and Rural Health to conduct research on health disparities in the region. The research is owned in partnership between the community and the university. The community must sign off on how and when the data are used, and community associates are coauthors on published papers. Community volunteers share the cultural awareness of those communities and their thoughts about what types of research should be done to address health disparities, said Lucky, while the researchers teach the community how to conduct research. “If you have a Ph.D. or a title in higher education, that is important,” said Lucky. “There are others who have a Ph.D. in community. It may look different, but the value should be equal,” she added.

Other people and organizations can help the foundation do its work in several ways, Lucky observed. They can identify networks of collaboration, resource sharing, and co-strategizing that already exist; creating something new is not always necessary. They can prioritize leaders and organizations that have the trust of their communities and the influence to get people to show up and speak out. They can also support southern community leaders and organizations that are able to articulate how identity, history, and politics combine to suppress the power and prosperity of their communities. The report As the South Grows on Fertile Soil by the National Center on Responsive Philanthropy in partnership with the Grant Makers for Southern Progress provides details on many of these opportunities.

Suggested Citation:"3 Leveraging Resources to Advance Equity in Rural Areas." National Academies of Sciences, Engineering, and Medicine. 2018. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24967.
×

Lucky concluded with the words of the poet Nikki Giovanni: “Take away our drums, and we will clap our hands. We prove the human spirit will prevail.”

THE APPALACHIAN COMMUNITY FUND

The Appalachian Community Fund has a mission similar to that of the Black Belt Foundation, observed Ashley Browning, an educational planner in the Office of Continuing Medical Education of East Tennessee State University’s Quillen College of Medicine and secretary of the board of directors for the fund. It works to build a sustainable base of resources to support community-led organizations seeking to overcome and address issues of race, economic status, gender, sexual identity, and disability in central Appalachia. Browning described the fund’s vision:

  • To work for the day when Appalachia’s land, air, and water are safe from destruction and contamination
  • Where the economy is stable, strong, and provides diverse employment opportunities for all people
  • Where government and industry are accountable to human needs without exploitation of people and their health
  • Where justice, equity, appreciation of diversity, and celebration of our common humanity replace racism, sexism, heterosexism, and other “isms”
  • Where wealth and resources are shared equally
  • Where all children grow up free from hatred and violence
  • Where justice overcomes oppression in any form

Appalachia has a powerful history, said Browning, as does Alabama and many other parts of the United States. Entrenched and sometimes corrupt local governments and lagging public policy have not generated sustainable economic alternatives in the region. It has strong ties to the coal industry and timber industry, with a strong dichotomy between owners and workers. She added that racism poses a major obstacle to the ability of groups to organize within communities and with each other in a broader social change movement. Racism is communicated powerfully and often subtly in society, Browning observed, and it exists even in communities and institutions where people of color are not physically present or are a small percentage of the community.

People in poverty tend to engage in more negative health behaviors, Browning noted. Some health care providers may think that the people they see do not have an attitude of responsibility for their own health. But Browning pointed out that if people feel defeated by poverty, unemploy-

Suggested Citation:"3 Leveraging Resources to Advance Equity in Rural Areas." National Academies of Sciences, Engineering, and Medicine. 2018. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24967.
×

ment, and a lack of social support, their health is not necessarily their top priority. She explained:

If nothing is getting better, if I am stressed and I can’t provide for my family and I feel no sense of connection, I am going to be more likely to give up. . . . Patients aren’t taking responsibility for themselves and aren’t following the instructions of their doctors because they have higher-level issues to consider.

The Appalachian Community Fund seeks to find the people who have been either forgotten or lost in the system and empower them to create change and make their communities what they want them to be, Browning said. It strives to be effective, responsible, accountable, democratic, antiracist, and committed to developing leadership. It believes that organizations need to work cooperatively and respectfully with each other and be accountable for their actions. The organization provides grants to community-based organizations that are working to end racism, sexism, classism, homophobia, ageism, and ableism; promote nonviolent communities; and build organizations that are fair, inclusive, and democratic. It supports a wide range of tools to work for social change, including community organizing, coalition building, community education, training, cultural work, and advocacy. The fund addresses systemic issues of inequity and forms of oppression, especially racism, with the understanding that the methods used to unlearn racism can also be applied to other isms, such as sexism and ageism.

With the 30th anniversary of the fund occurring shortly after the workshop, it has been engaged in a deeper form of needs assessment than it usually does. It has been listening to communities about their problems. “Tell me what is going to work to fix it,” said Browning, adding that “if we are on board as a group, the money is yours to go after it.”

The following are examples of work that the fund has supported:

  • Reaching 5,000 undocumented immigrants in Tennessee with information about using the Obama administration’s administrative relief to avoid deportation
  • Connecting chemical safety with racial justice at a summit of 62 residents, community activists, local government officials, academics, youth, and scientists
  • Challenging and postponing a road project that would have destroyed Chattanooga’s historic African American Lincoln Park neighborhood and its old Negro League ballfields
  • Examining, with an interracial group of middle school students, the effects of urban renewal, gentrification, structural racism, and classism in their own backyards
Suggested Citation:"3 Leveraging Resources to Advance Equity in Rural Areas." National Academies of Sciences, Engineering, and Medicine. 2018. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24967.
×

The fund’s grantees include Centro Hispano, a nonprofit organization and welcoming center for multicultural families in East Tennessee; Chattanooga Organized for Action, a nonprofit organization that works to initiate, support, and connect popular grassroots organizations for the purposes of advancing the local social justice movement; and the UUNIK Academy,2 which is a rite-of-passage program dedicated to transforming African American youth into respectful and respectable African American adults. In addition, it has cooperated with the Nurse–Family Partnership program, the Office of Continuing Medical Education at East Tennessee State University, and child care centers in the region. The work with the university, for instance, led to a pediatrics education program that allows rural providers who do not have access to pediatric specialists to ask for assistance in treating their patients in rural areas.

“To have an empowered Appalachia, we have to first empower the individuals,” Browning concluded. She added:

Empowerment is what brought me to the Appalachian Community Fund in the first place. Being from Eastern Kentucky, my dad was a railroader and my entire family were coal miners. [When] I found other people who were like minded and had the same struggle that I did, it was night and day.

THE CON ALMA HEALTH FOUNDATION

The mission of the Con Alma Health Foundation is to be aware of and respond to the health rights and needs of the culturally and demographically diverse people and communities of New Mexico, to improve health status and access to health care, and to advocate for health policies that will address the health needs of all. The foundation seeks to engage multifield and multisector stakeholders, including the public sector, the business sector, and the private nonprofit sector, explained Dolores Roybal, the foundation’s executive director. The foundation prioritizes building on existing assets and funding systems change.

The foundation is largely a grant-making organization, with a particular focus on culturally diverse rural and tribal communities. For example, Roybal mentioned a partnership with Grantmakers in Health to locally match funding from the Robert Wood Johnson Foundation for a state grant-writing assistance fund. One of the resulting proposals brought in $34 million to New Mexico to help plan the health insurance exchange.

A collaboration between Con Alma and the Kellogg Foundation resulted in a 2-year assessment of the effect of the Patient Protection and Affordable Care Act (ACA) in New Mexico from a health equity perspec-

___________________

2 UUNIK is an acronym that encompasses five of the seven principles of Kwanzaa.

Suggested Citation:"3 Leveraging Resources to Advance Equity in Rural Areas." National Academies of Sciences, Engineering, and Medicine. 2018. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24967.
×

tive. The foundation has also partnered indirectly with The Colorado Trust to produce a report modeled on The Colorado Trust report Health Equity and the Affordable Care Act (DeLay and Walker, 2013).

The foundation worked with Hispanics in Philanthropy to create a funders’ collaborative for Strong Latino Communities and the Latino Men and Boys Initiative, which resulted in awards of nearly $2 million to New Mexico nonprofit organizations. “Con Alma’s contribution was probably no more than $25,000,” said Roybal. “Again, it is through working together that we were able to leverage those resources.”

A 3-year initiative called Healthy People, Healthy Places was supported by a group of national and New Mexico funders, with Con Alma contributing one-third of the funding. This funding expanded the foundation’s work in health equity beyond ethnic and racial disparities to the built environment and food access policies, explained Roybal. It has made multiyear grants to the New Mexico Center on Law and Poverty Healthcare Access Project, which has been working to remove barriers to Medicaid or exchange coverage for low-income individuals, and to the New Mexico Community Health Worker Association to recruit, train, and mentor community health workers to assist with the certification efforts of the 2014 Community Health Worker Act in New Mexico, which allows promotoras to receive reimbursement through third-party payers for their work.

Smaller grants have gone to Prosperity Works, which leverages resources and invests in families by removing barriers and opening paths to opportunities through a child savings account, and Las Cumbres Community Services to increase participation in policies that address barriers to safe and affordable housing for pregnant women, children, and families.

As these grants demonstrate, said Roybal, the core values of the foundation are community self-determination, diversity, and preservation and enhancement of cultural and spiritual assets. The foundation’s focus is health equity rather than health disparities, she added, with health broadly defined to include behavioral health, oral health, environmental health, spiritual health, and well-being. “Health is much more than health care. That is why we fund things like housing, transportation, economic development, et cetera,” she said.

The foundation uses a shared leadership model. A community advisory committee, which provides community outreach and needs assessment, is involved in financial oversight, strategic planning, grant making, and evaluation. An annual meeting of the community advisory council and board of trustees provides an opportunity to discuss governance, legal, and fiduciary issues. “This is a truly integrated model,” said Roybal, explaining that “we are community led and community serving.”

Suggested Citation:"3 Leveraging Resources to Advance Equity in Rural Areas." National Academies of Sciences, Engineering, and Medicine. 2018. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24967.
×

Roybal discussed some of the differences between health disparities and health equity in the context of her foundation. Focusing on health equity shifts attention to the systemic issues that affect health outcomes. As the New Mexico Health Equity Working Group states on its website,3

Health care is only a small part of what really affects our health. The choices we make, our behavior, has a large impact on our health. But, the places where we live, work, and play—our social conditions—affect the choices we make.

As Roybal said, “We believe that health equity is where everyone has the right to good health regardless of zip code or skin color.”

One-third of New Mexico is rural, which is above the national average. It is a majority minority state, said Roybal, with a population that is about 50 percent Hispanic, 10 percent Native American, and 3 percent African American, along with other ethnic and racial groups, and it is becoming more diverse. It is the fifth largest state in the nation, and infrastructure is lacking in some areas. For the state as a whole, racial and ethnic minorities suffer higher rates of mortality and illness compared with other groups and receive a lower quality of health care, she explained. Furthermore, rural poverty rates are higher than in urban areas, which can increase disparities for minorities in rural areas.

Roybal grew up and still lives in a rural community that is predominantly Hispanic and Native American. “I did not know that I was ‘poor’ until I went to do my graduate studies at the University of Denver,” she said. “We owned our own homes. We had land. We had a barter system. We would exchange a truckload of wood for potatoes or apples or chili. We were just fine. I think that sometimes these definitions . . . can have an impact on populations and on communities that is a bit misguided,” she said.

New Mexico is grappling with many issues that are of concern elsewhere. Health care policy, Medicaid, and immigration are of particular interest to New Mexico and have been a focus of national discussions. The state’s population is getting older on average, and rural communities have higher percentages of older people. Many grandparents are raising grandchildren, which has been an increasing trend across the country. “We are kind of a microcosm for the rest of the nation,” said Roybal. She concluded with the following:

That is an opportunity. . . . Rural communities are very resilient and resourceful and innovative. We shouldn’t just be doom and gloom when we are talking about rural communities. We have strong values, in terms of being community based, family based, and intergenerational. . . . That

___________________

3 See http://nmhewg.weebly.com/resources.html (accessed October 23, 2017).

Suggested Citation:"3 Leveraging Resources to Advance Equity in Rural Areas." National Academies of Sciences, Engineering, and Medicine. 2018. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24967.
×

is why we do all of our work from an assets-based perspective rather than a disparities perspective.

MULTISECTORAL COLLABORATION

A major focus of the discussion session was how to best collaborate with other sectors, including business and government. Roybal offered a story. When the ACA was first implemented, the Con Alma Health Foundation went to advocates to organize a multisector advisory committee, but advocates said that they did not want to work with government representatives, and when the foundation approached government representatives, they said that they did not want to work with advocates. In the end, “they all came because they didn’t want to be left out. They all worked together. They came up with this outstanding plan that was a true blueprint,” she explained. Even though they could not agree on a small part of the report, they agreed to disagree. Roybal said, “Alone, we get to move from point A to point B, but together and collectively we can move from point A to maybe point Z.”

Browning said that the Appalachian Community Fund uses a system based on concentric giving circles. When individuals from a community identify a problem, a fund is established to which different organizations can contribute. These giving circles have greatly improved the sustainability of programs, she said. The fund is also able to provide more tailored grants:

We are doing a technical assistance program for our 30th anniversary, where we are providing thirty $3,000 grants to applicants who need technical assistance. Three thousand dollars doesn’t sound like a whole lot, but when you are talking about a social movement in Eastern Kentucky that can’t afford a computer to mine data, that means all the difference in the world to them.

Lucky said that the Black Belt Community Foundation both approaches and is approached by other organizations. An early lesson occurred when a university approached the foundation and asked to partner. “Once we learned and saw our own value, we went to the Alabama State Council on the Arts and said, ‘One of the things that we can help you do, because you are a statewide entity, is help provide you access into communities that you aren’t readily serving.’ Until we recognized our power, we didn’t know to do that,” she said.

The three panelists also, in response to a question, talked about their work with faith-based organizations. “In the Black Belt region, we have worked from day 1 very deeply with our faith-based community,” said Lucky. For example, a recent project with young men and boys of color involved faith-based communities throughout the region. She explained:

Suggested Citation:"3 Leveraging Resources to Advance Equity in Rural Areas." National Academies of Sciences, Engineering, and Medicine. 2018. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24967.
×

When you have churches on every corner [with] the ability to influence large numbers of people, we have considered it very valuable. We have had to use some different approaches sometimes to get the faith community involved, but it has been worthwhile and has yielded great results for us at the end of the day. They have become a part of our board. They have served on committees with us. They see themselves as a part of the infrastructure of the Black Belt Community Foundation.

Similarly, the Department of Health in her region has a partnership with faith-based communities in addressing substance abuse issues, said Browning, adding that “what better resource do we have to tell people that it is okay to be an addict and still attend church?” Churches can provide people with resources such as support groups that incorporate a faith-based component into their recovery. About one-third of the Appalachian Community Fund’s grantees are faith-based institutions that are doing work in their communities. “The stronger we can make those relationships, the more allies we have to fight the issues that we are fighting,” Browning observed.

Finally, Roybal said that her organization approaches the issues both structurally and philosophically. Structurally, it encourages fiscal sponsorships so funders can get grants to organizations that are not necessarily set up to receive grants. Philosophically, it values diversity of thinking. “We ensure that we have different opinions, including faith-based opinions, on our board, our community advisory committee, and our staff,” she said.

Suggested Citation:"3 Leveraging Resources to Advance Equity in Rural Areas." National Academies of Sciences, Engineering, and Medicine. 2018. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24967.
×
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Suggested Citation:"3 Leveraging Resources to Advance Equity in Rural Areas." National Academies of Sciences, Engineering, and Medicine. 2018. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24967.
×
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Suggested Citation:"3 Leveraging Resources to Advance Equity in Rural Areas." National Academies of Sciences, Engineering, and Medicine. 2018. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24967.
×
Page 21
Suggested Citation:"3 Leveraging Resources to Advance Equity in Rural Areas." National Academies of Sciences, Engineering, and Medicine. 2018. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24967.
×
Page 22
Suggested Citation:"3 Leveraging Resources to Advance Equity in Rural Areas." National Academies of Sciences, Engineering, and Medicine. 2018. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24967.
×
Page 23
Suggested Citation:"3 Leveraging Resources to Advance Equity in Rural Areas." National Academies of Sciences, Engineering, and Medicine. 2018. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24967.
×
Page 24
Suggested Citation:"3 Leveraging Resources to Advance Equity in Rural Areas." National Academies of Sciences, Engineering, and Medicine. 2018. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24967.
×
Page 25
Suggested Citation:"3 Leveraging Resources to Advance Equity in Rural Areas." National Academies of Sciences, Engineering, and Medicine. 2018. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24967.
×
Page 26
Suggested Citation:"3 Leveraging Resources to Advance Equity in Rural Areas." National Academies of Sciences, Engineering, and Medicine. 2018. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24967.
×
Page 27
Suggested Citation:"3 Leveraging Resources to Advance Equity in Rural Areas." National Academies of Sciences, Engineering, and Medicine. 2018. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24967.
×
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Rural counties make up about 80 percent of the land area of the United States, but they contain less than 20 percent of the U.S. population. The relative sparseness of the population in rural areas is one of many factors that influence the health and well-being of rural Americans. Rural areas have histories, economies, and cultures that differ from those of cities and from one rural area to another. Understanding these differences is critical to taking steps to improve health and well-being in rural areas and to reduce health disparities among rural populations. To explore the impacts of economic, demographic, and social issues in rural communities and to learn about asset-based approaches to addressing the associated challenges, the National Academies of Sciences, Engineering, and Medicine held a workshop on June 13, 2017. This publication summarizes the presentations and discussions from the workshop.

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