American Lutherans have had a longstanding foreign involvement with Madagascar through pre-colonial evangelical missions that began on the island in 1888 and continued for over a century. This book explores Lutherans’ efforts to institute an aid alliance that departs from the inequalities of the earlier mission work on the island. Focusing on a 30-year-old medical aid program between Lutherans in Madagascar (Fiangonana Loterana Malagasy) and the U.S. (after 1988, Evangelical Lutheran Church in America), it provides a close analysis of the tensions among humanitarian activity, capitalism and global religious fellowship. Since the early 1980s, Lutherans have pursued an increasingly common aid model that entails sending from Minneapolis to Antananarivo the often unused medical discards of the U.S. medical establishment, created primarily by planned obsolescence or biomedical innovation. The book draws upon twenty-four months of primary ethnographic research in the Midwest U.S. and shorter research periods in Madagascar among Lutheran clinicians, aid workers, volunteer laborers, healer-evangelists and former missionaries. It develops an approach to Christian aid spaces as “conversionary sites,” or under-analyzed cultural spaces that operate as busy moral crossroads between past and present, as well as between geographically dispersed religious communities and global commodity chains. The book therefore maintains that contemporary biomedical aid from the United States to Madagascar is a multifaceted cultural and historical transaction; it is an ongoing, incomplete conversion of the moral foundation, practices and ways of knowing tied to the colonial legacy.