Denise Houseman was near death. She weighed 98 pounds and was bedridden with a high fever and open ulcers over her abdomen.
The year was 1985, and Houseman, then 17, had Crohn's disease but had never been seen by a doctor. Her family's church -- Faith Tabernacle -- forbade it.
Houseman was told to pray harder.
A fundamental church, Faith Tabernacle rejects any form of medical care. The church believes disease is a moral issue, the result of being out of relationship with God. The remedy must be a spiritual one.
These believes have once again come under scrutiny after the death of toddler whose parents -- members of Faith Tabernacle --abided by their religious convictions and relied on prayer rather than medicine.
Ella Grace Foster was two when she died in November from pneumonia. Authorities say she likely would have survived had she received medical care.
Authorities earlier this month charged Jonathan and Grace Foster of Berks County with involuntary manslaughter and child endangerment. The Fosters, who are members of Mechanicsburg-based Faith Tabernacle congregation, attributed the toddler's death to "God's will."
"Any illness or injuries that occur within their lives are considered acts of God, and they leave all of their faith in God to keep them safe, healthy and debt free," Jonathan Foster told authorities, according to court records.
Ella's death adds to the roster of children who every year die as a result of having been denied medical attention on the grounds of religious convictions. In almost all the cases, children have died from diseases or conditions that could have been treated with medicine.
Pennsylvania is one of 32 states that offer a religious exemption to state child abuse protection laws. The statute extends a religious defense, in civil court, to parents who rely on spiritual treatment in accordance with their faith's beliefs.
That exemption does not protect them from criminal prosecution. Religious exemptions don't apply in cases in which a child dies.
"We've failed our children here," said Dr. Paul Offit, professor of pediatrics at Children's Hospital of Philadelphia and long-time advocate dedicated to overturning Pennsylvania's religious exemption. "I think this in many ways is America's dirty little secret."
Offit was a young pediatrician in Philadelphia in the early 1990s when a nationwide measles outbreak surfaced in the Faith Tabernacle school in the city.
Faced with a catastrophic public health crisis, health officials scrambled to secure legal remedies to compel Faith Tabernacle parents to vaccinate their children. By the time the court order was handed down, the measles outbreak had claimed the lives of nine children, six of them belonging to the church.
In 1985, Houseman's condition was so grave, her older brother, who by then had left the church, drove her to Polyclinic Hospital in Harrisburg.
She spent three weeks in intensive care, not once visited by relatives. Upon her release from hospital, Houseman walked away from her church and never looked back.
Even so, she argues that Faith Tabernacle parents are good parents.
"These are good people," said Houseman, who lives in Fairview Township with her husband and two sons. "They are not monsters. These are people who are working with other people in the community. They don't take a penny from the state. They work two and three jobs. They bring up kids with ethics... They are hardworking and responsible."
PennLive tried repeatedly to speak to Faith Tabernacle leadership for this story. Requests were not granted.
Houseman acknowledges that the idea of putting a child's life at risk in the name of religion might be an unfathomable conviction for some people.
"It's not cut and dry," she said. "For people to say horrible things about the Fosters, well they are just being judgmental. These are good people who don't know any better."
Houseman was one of 11 children of Fred and Jeannette Zehring of Harrisburg. The family attended the Faith Tabernacle congregation once located off 19th Street. The church closed its doors some years ago and was absorbed by sister congregations in Lebanon, Mechanicsburg and Philadelphia.
Houseman and her siblings -- like all children of the Faith Tabernacle community -- attended the church school. Faith Tabernacle, which had evolved out of the healing movement that flourished in the U.S. in the late 1800s, espouses an insular community shielded from outside influence.
Faith Tabernacle families are generally big; a family of 12 is not uncommon. Houseman's yearbooks, The Tab-let, depict a wholesome community. Classes were relatively small, and many of the children and faculty are linked by marriage and blood lines.
Women wear only dresses. Slacks, the church teaches, show off a woman's figure. Families eschew television, radio and popular music. All have the potential of leading the into sin.
"Life was very simple," Houseman said. "Is that really a bad thing? There was a lot of good in it."
Faith Tabernacle rejects any and all forms of medical intervention, from vaccinations to visits to the doctor's office.
Church members are forbidden to wear glasses or hearing aids. They may not use canes or walkers. Children are not vaccinated. Aspirin, Advil, cough syrup, thermometers -- anything not directly linked to prayer -- is forbidden. Herbal teas that impart medicinal properties, such as chamomile tea, are banned.
Women are forbidden to use tampons (the church believes they compromise a woman's virtue). Midwives are not allowed during childbirth, although the presence of an experienced woman is not discouraged. Alcohol and cigarettes are rigorously banned, as is premarital sex.
"It's a way of life," Houseman said. "If you are not exposed to anything else, how do you know any different, unless you are put to the test or something like this."
Rita Swan says dogmatic faiths typically foster strong bonds among its flocks, the church community providing a powerful support network for an otherwise marginalized group.
"This sets up a sense of superiority to mainstream culture that can be dangerous," said Swan, whose own story emerged out a faith healing community.
In 1977, Swan and husband Douglas were devout members of the Christian Science church. That year, the condition of their son Matthew, who had been sick with high fevers, began to deteriorate.
"We were told to have more faith in God," she recalls.
Against the wishes and orders of their church, the Swans took their child to the hospital, but it was too late. Diagnosed with meningitis, Matthew died after a week in the ICU.
The Swans left the church. For the past 40 years, Rita Swan has been on a mission to overturn religious exemptions at the state level across the country.
Faith-healing communities themselves remain a formidable opponent.
"Religion is not something that encourages a lot of skepticism," said Swan, head of Children's Healthcare Is a Legal Duty, or CHILD, a Lexington, Ky.-based nonprofit that works to end religion-based child medical neglect across the country. "Every religion has an area where you can't ask questions and you have to accept it. With Catholics it's the pope. With fundamentalists it's the Bible. With Christian Scientists and charismatic Pentecostals, it's their faith healing."
In the absence of scientific rationale for disease, faith healing traditions affirm by trial and error their conviction that God can intercede in all illnesses, conditions and diseases.
"They all have experiences of being sick and they prayed and then the symptoms changed and they are predisposed to believe that God affected this," Swan said. "It's very precious to them. That's how God becomes real to them."
Such intervention is unlikely to have an impact in cases of Type 1 diabetes or bacterial meningitis.
"What happens with faith-healing folks when their children die is that they stand back and say 'I need to get close to God. I need to pray more,'" said Offit, author of the book, "Bad Faith: When religious belief undermines modern medicine."
"They don't say 'I just let my child die unnecessarily. As a parent your job is to protect. You give up your life for your own child. To say you caused your child's death is the hardest thing to do."
Pennsylvania's religious exemption law, like all others across the country, is a vestige of the Nixon administration.
Prominent in Richard Nixon's cabinet were two members of the Christian Science faith: H.R. Haldeman and John Ehrlichman, whose historic footnote would be sealed not by provisions in health law but their role in the Watergate scandal.
Haldeman and Ehrlichman used their power and influence to shepherd into federal law provisions that exempted from prosecution members of faith-healing churches, of which Christian Science is one. In order for states to receive federal funding, they had to extend religious exemptions to faith-healing communities.
The federal standard has been revised, but the 49 states that passed the law (Nebraska abstained) have had to deal with the state statutes. At least seven have repealed them. Six others, including Idaho, offer a faith-based shield for felony crimes such as manslaughter.
Over the years, the statutes have been at the center of court cases involving scores of children who have died as a result of a family's religious defense.
In Pennsylvania, the Faith Tabernacle and the Amish communities account for many of those deaths. The latter do not have doctrinal opposition to medical care, but tend to favor natural remedies. In addition, the Amish tend to stay away from medical care out of concern that it will burden the faith community. The Amish do not subscribe to health insurance and believe that the community as a whole should bear the cost of a family's medical expense.
The courts, however, have been relatively lenient over the years.
In 2013, for instance, Naomi and John Stoltzfus of Lancaster County pled guilty to charges in the death of their child, who died April 21 of that year of sepsis caused by pneumonia. The Pennsylvania Department of Public Welfare cited the case as:
"The parents stated that the child had been sick for 10 days with high fevers for a period of eight days. The parents are of the Amish faith and stated that they were using natural remedies to treat the child."
Authorities determined that the child could have been treated and would have survived with prompt medical attention and as little as $5 worth of medication. The parents were both charged with one count misdemeanor endangering the welfare of a child and one count misdemeanor recklessly endangering another person.
They were sentenced to seven years of probation and ordered to attend parenting classes.
"The Amish almost never are challenged," Swan said. "There is an awful lot of sentiment about them. People respect these quaint passivist people ... they are gentle conscientious objectors."
In the wake of the Jerry Sandusky child sex abuse case, Pennsylvania's child abuse law was strengthened in 2014. The law holds that religious exemption does not apply in cases where failure to provide needed medical or surgical care causes the death of the child.
The law allows Children and Youth Services to monitor and intervene even if there is a religious exemption. The religious exemption provision does not relieve the obligation of mandated reporters.
Pennsylvania's new law reinforced provisions pertaining to child abuse but left the religious exemption provision intact.
Child advocates and the medical community largely acknowledge the right to religious freedom, but most want to draw a line when it comes to the welfare of children.
"This is a case where the personal views of the parents involved caused them to not seek routine health care for a condition that could have been treated and resulted in a child remaining alive," Dr. Benjamin Levi, a medical ethicist at Penn State Milton S. Hershey School of Medicine, said of the Foster case. "That violates legal guidelines and violates ethical tenets and basic societal norms."
Maria McColgan, a child abuse pediatrician, wants to see the pendulum swing in favor of children and away from religious freedom.
"A two-year-old child is too young to choose to die and choose not to seek medical care because of religious reasons," said McColgan, a pediatric advisor with Prevent Child Abuse in Pennsylvania and pediatrician at the CARES Institute in New Jersey, which specializes in treatment for abused children.
"Children have the right to medical care. They have a right to live. It's not fair for a parent to impose their belief on them to the point of death."
Physicians, in fact, routinely petition courts to override the wishes of parents who oppose medical care for their sick children on ideological or religious views grounds. Often, the request is summarily granted.
"If a child is at risk from a treatable condition," Levi said. "I don't know any responsible medical professional who would let that child die because the parents did not believe in medical treatment."
When accommodations can be made, most medical professionals will work to respect the parent, Levi said. For example, when working with patients of the Jehovah Witness faith, which prohibit blood transfusions, a physician might delay blood transfusion and allow the condition to revert itself.
"There are a varieties of different ways to try to accommodate deeply held religious beliefs," Levi said.
Child protection services are mandated by law to monitor children deemed at risk and intervene when it appears the condition will result in the death of the child or cause long-term adverse health conditions.
That doesn't always guarantee that a child's death will be averted.
In recent years, among the more than two dozen deaths in Pennsylvania involving faith healing, child protection services had visited the child's home and checked on the children in most cases.
In such cases, Children and Youth Services generally can't be held responsible unless it can be demonstrated that they knew the child was going to die.
"Lots of people have pneumonia and don't die," said Lucy Johnston-Walsh, a clinical professor of law at Penn State Dickinson School of Law and director of the Center on Children and the Law. "Did they know it wasn't serious and do nothing?"
Trying to convince legislatures to repeal religious exemptions remains a perennial battle for advocates, particularly amid the growing tide of conservative legislatures that favor religious freedoms.
The tide has been turning, and nowhere as dramatically as in Oregon.
Beginning in the late 1990s and into 2009, Oregon saw a string of high-profile children's deaths in the reclusive Followers of Christ church in Oregon City. The compelling and troubling deaths attracted international attention and compelled Swan to move to Oregon and join coalitions and advocates intent on striking the religious exemption provisions from the law.
Advocates succeeded. In 2009, the Oregon legislature repealed all nine exemptions pertaining to the medical care of children in Oregon.
"I'm proud to say there has not been a child die in Followers of Christ since September 2009," Swan said. "That proves to us that changing the law does change parental behavior."
Since then, several members of the fundamental church have been successfully prosecuted in Oregon, including Dale and Shannon Hickman who in 2011 were convicted of second-degree manslaughter after their newborn son died of a simple infection.
Offit said he is pleased that the Berks County district attorney's office charged the Fosters.
"I'm glad to hear he thinks he can prosecute that case," he said.
The Fosters on Wednesday surrendered custody of their six other children.
Houseman, who to this day lives with the long-term health effects of her near-death experience, insists government must step in and force Faith Tabernacle parents to take their children to doctors and hospitals.
"These parents will abide by the law," she said. "They are law abiding people... right now nothing is compelling them. They will comply..they will comply with the law."