AIDS, Africa and the Catholic Church

Moving beyond simplistic assumptions First in a Three-Part Series

Last Wednesday, Paul Wolfowitz, a former Bush Administration official who was one of the chief architects of the Iraq war, assumed the Presidency of the World Bank. In his opening address to his staff and the press, Wolfowitz singled out the continent of Africa to be the central focus of his work at the Bank, expressing his wish to transform it “from a continent of despair, to a continent of hope.”

Given his political background and the malevolent effect many feel the World Bank and its sister institution the International Monetary Fund (IMF) have had in the developing world, there are many doubts about whether Wolfowitz will be able to engineer such a transformation. One thing is certain though; the current social and economic conditions in Africa are truly desperate. More than 300 million of the continent’s inhabitants live on less than one dollar a day, and per capita income on the continent has fallen over ten percent in the last two decades. It is no coincidence that this poorest continent is the site of a deadly AIDS pandemic where an estimated 25 million Africans have HIV/AIDS, representing 70 percent of the AIDS cases in the world. Each year, over 2 million people on the continent die from the virus, and more than 12 million of Africa’s children have suffered the loss of at least one parent to AIDS.

This is the first installment of a three part series examining the Church’s response to the AIDS crisis in Africa. There are many who are quick to criticize, even condemn, the way the Church has approached this issue, often focusing specifically on its moral objections to condom use. Yet such criticisms often fail to grasp the realities of the AIDS pandemic by reducing the solution to a complex problem to a small piece of rubber latex. In truth, the Church has spoken more prophetically and acted more heroically in response to the AIDS crisis in Africa than it is typically given credit for. And while much of the world community continues to point fingers and assign blame the Church has made a real impact by providing essential care to victims as well as changing the international policies that have allowed the AIDS crisis in Africa to become so dire.

This first piece will look at the Church’s efforts to cultivate economic justice, and so address the poverty and inequality that are the root causes of the pandemic. The second installment will look at the direct care the Church is administering on the ground to AIDS patients and children orphaned by the disease. The final installment will examine the discussion surrounding the use of condoms as a risk reduction method against contracting the virus, as well as the effects of other behavioral change approaches like promoting increased marital fidelity and sexual abstinence.

Poverty, Neoliberalism and AIDS
The root cause of the African AIDS crisis is an economic one. It is only because of the continent’s rampant poverty that this pandemic has been able to develop and perpetuate itself on its current scale. The link between poverty and a variety of health risks, including AIDS, has long been established. In 1995, the World Health Organization began their annual report by identifying “extreme poverty” as “the world’s biggest killer and the greatest cause of ill-health and suffering across the globe.” According to the report, “Every year in the developing world 12.2 million children under 5 years die” from preventable illnesses. “They die largely because of world indifference, but most of all they die because they are poor.” The fact is the poor in Africa are only getting poorer; Africa’s per capita income dropped ten percent between 1980 and 2000.

In 1995, the World Health Organization began their annual report by identifying “extreme poverty” as “the world’s biggest killer and the greatest cause of ill-health and suffering across the globe.”… The fact is the poor in Africa are only getting poorer; Africa’s per capita income dropped ten percent between 1980 and 2000.

While such facts are harrowing, it is sad to note that neoliberalism–the dominant economic model in Africa in recent decades–has only contributed to continent’s growing impoverishment. Neoliberalism is based on a radical ideology that contends that the market alone should determine the shape of the economy. In examples spanning the globe, neoliberalism has proven to create economic conditions that favor the rich and hurt workers and others who are poor. Not surprisingly, neoliberalism’s main boosters have come from the corporate boardrooms of the West, as well as the elite of the developing world. This economic model has been central to the global economic agenda of every US president since Reagan, and influential members of both the Republican and Democratic Parties have embraced it.

The process of implementing neoliberalism in Africa has not been without its share of coercion. In the early 1980s, many African countries fell into a debt crisis when the floating interest rates on their state-held loans skyrocketed in reaction to the rapid and dramatic increase of US interest rates by the US Federal Reserve. As a result, required interest payments magnified many times over, and debt burdens that were once manageable became poised to push many African nations into default, causing great panic among the private Northern banks that held the loans to the developing world. With the international lending system on the verge of a crisis, multilateral lending institutions, like the International Monetary Fund (IMF), controlled by the advanced capitalist countries of Europe and North America, stepped in to loan developing countries the capital required to keep making minimal interest payments on their debt.

However these bailouts came with conditions, as countries receiving IMF loans were required to implement programs of “structural adjustment” which imposed strict fiscal austerity on governments and forced countries to liberalize their markets. This IMF-imposed fiscal austerity led governments to cut basic services like education and healthcare; this forced liberalization decimated local economies and opened the door to jobs relying on cheap wages and limited labor protections. Yet despite reeking havoc among the poor, these policies have only trapped many African countries in a continuous cycle of debt, even though they have paid off their initial loans many times over. Nigeria, for example, has paid over $16 billion back on its original $5 billion loan, yet still finds itself owing $32 billion for that same debt. According to Jubilee USA, for every dollar of foreign aid Africa receives, it pays out $1.30 to rich countries in debt service. IMF figures put the annual amount of debt payments from sub-Saharan Africa at $14.5 billion, an amount over four times the amount the region’s governments spend on healthcare.

One of the cruelest facts about neoliberalism is that, in its idolatry of the market, it assigns greater preference to the agents of profit maximization than the essential needs of people. A clear example of this is the strict patent laws–or “intellectual property rights protections” in corporate parlance – insisted on by neoliberal powerbrokers. These patent laws, by banning generic drug production and importation, effectively grant pharmaceutical giants monopolies over certain medicines, including vital AIDS treatments, allowing them to set inflated prices. As a result, potentially life-saving drugs are priced out of the reach of most Africans with AIDS.

The Church’s Response to Neoliberalism
The Church has been steadfast in condemning neoliberalism. Pope John Paul II bluntly observed in 1999 that, “More and more […] a system known as “neoliberalism” prevails; based on a purely economic conception of man, this system considers profit and the law of the market as its only parameters, to the detriment of the dignity of and the respect due to individuals and peoples.”

John Paul noted that “unsustainable economic programmes are imposed on nations as a condition for further assistance” by institutions like the IMF, resulting in “a small number of countries growing exceedingly rich at the cost of the increasing impoverishment of a great number of other countries; […] the wealthy grow ever wealthier, while the poor grow ever poorer.” Disapproving of drug patents that denied people access to medicines, John Paul called for “a ‘social mortgage’ on all private property,” including “‘intellectual property,'” noting that the needs of the human community trump absolute ownership rights.

The Church has gone beyond just rhetoric. In the 1980s, the Church in Africa, from the laity up through the bishops, became a strong voice in the growing movement in the developing world advocating for the complete cancellation of the debts of heavily impoverished countries. Soon, the movement claimed John Paul as one of its earliest and most public supporters. In his 1994 apostolic letter, Tertio Millennio Adveniente, John Paul invoked the biblical tradition of the jubilee year to make debt cancellation an integral part of the Church’s millennial vision. In a 1999 audience with leaders of the debt movement, John Paul praised their efforts and called the need for debt relief “urgent.” He also expressed concern that “progress in resolving the debt problem is still so slow,” noting, “It is the poor who pay the cost of indecision and delay.”

The US Conference of Catholic Bishops also issued statements favoring debt cancellation in 1989 and 1999. And all over the world, many Catholic lay people, clerics, and religious have been tremendously active in the social movements for debt cancellation and an alternative to neoliberalism.

With campaigners feeling comprehensive debt cancellation may finally be within reach at the upcoming G-8 summit in July, Catholics continue to mobilize against debt. In advance of this meeting, the Kenyan Bishops’ Council issued a powerful pastoral letter referencing the parable of the beggar Lazarus from Luke’s Gospel (16:19-31). It reads: “The rich man can easily be seen as representing the North, while poor Lazarus the underdeveloped South. […] The efforts at debt cancellation that were made till now could be compared to the scraps that Lazarus hoped he could feed on at the rich man’s table: they are illusory promises without real substances. Lazarus still died of hunger and disease! Besides, eating scraps of food that fall from a table is not in line with the dignity of human beings: it is fitting for pets! Giving to others scraps rather than what they deserve means basically treating them in a sub-human way, not as human beings!”

While debt cancellation for at least the world’s poorest countries can hopefully be achieved this summer, there is still a long way to go in the struggle to create a just economy in Africa. Pope Benedict XVI, the new leader of the Universal Church, shares his predecessor’s concern about the unjust effects of “unbridled capitalism.” Under his pontificate, the Church will continue to be a prophetic force in confronting the poverty and economic injustice that are at the roots of the African AIDS crisis. The Church will also continue its initiatives in Africa providing care.

“The Church is reaching out to those infected and affected by HIV,” said Fr. Edward Phillips, a missionary priest from Boston serving in Kenya, in a presentation at the 2000 International AIDS Conference. “We are called to love them unconditionally and to be Christ in their midst.”

The Church has taken this calling very seriously. Catholic agencies and institutions provide over a quarter of the total care given to people with HIV and AIDS around the world. Much of these efforts have taken place in the global south, where the Church is filling the void left open by diminished government health spending in accordance with IMF structural adjustment mandates. This ministry of the Church is especially important in Africa, where every day upwards of 6,000 people die of AIDS.

The Church in Africa has been integral in providing critical health care services to people living with AIDS, particularly the very poor, who would not otherwise have access to physicians, registered nurses, medicines and other treatments. In Dar es Salaam, Tanzania, a Catholic AIDS health center known by the acronym PASADA (Pastoral Activities and Services for people with AIDS in Dar es Salaam Archdiocese) reports receiving over 700 patients each week for free treatment. An additional 200 take advantage of the center’s on-site testing and counseling services.

AIDS ravages not only the body of those it infects, but the spirit as well. For Catholics ministering to people with AIDS in Africa, healing the spiritual effects of the virus go hand in hand with healing its physical effects.

“AIDS patients suffer physically but more so they suffer emotionally and spiritually,” says Fr. Phillips about his ministry on the Maryknoll Africa website (link below). “Many AIDS patients wonder whether God really loves them and can forgive them. AIDS patients are much like the rejected of the Gospels. Jesus reached out to them and let them know that they were special to Him, AIDS ministry invites us to reach out to our patients as Jesus did. Our action of unconditional love and acceptance of our patients is the first step for many of our patients to believe that they are lovable. This unconditional love leads many of our patients to seek out spiritual peace in their lives.”

Local organizations of lay ministers, known as small Christian communities, have been integral to these efforts at healing both the body and the spirit. Each day, teams from these small Christian communities visit people with AIDS at their homes, providing them treatment, nutritional services, support, and consolation. Many of these lay volunteers are people who are HIV positive themselves. Knowing with great intimacy the challenges of living with AIDS, they feel called to help others in similar situations.

Sr. Veronica Schweyen, who works closely with the small Christian communities in Tanzania, shares a memory on the Maryknoll Africa site about one of the lay AIDS ministers, Emarysiana Kitwala: “One day I was called to the home of a man covered with sores, and there I met Emarysiana washing the man’s open wounds. Not even his immediate family members would help him. I have seen Emarysiana give of herself for six years, and she never counts the cost to herself. She’s a woman who truly gives me and others courage.”

A prenatal clinic in Lusaka, Zambia reports that 35 percent of the pregnant women who come in are HIV positive. Because of their economic dependence, many African women have few available avenues of recourse when their husbands are unfaithful and thus put them at risk of contracting the disease. Additionally, when a male breadwinner dies or disappears, women are often forced to contemplate the risk of prostitution, a service for which there seems to be a stable demand, as the only viable way of providing for themselves and their families.

The small Christian communities also assist with efforts aimed at education and prevention, often speaking at schools, parish events, and other local forums. Since many of the volunteers are HIV positive, they share their own experiences as a way to help others learn about the virus. By being a presence in the neighborhood or village, the small Christian communities are helping to defeat the stigmas attached to AIDS in many parts of African society. In the past, these stigmas have silenced discussion about how the virus is contracted, led to the spread of myths about AIDS, kept infected people from seeking testing or treatment out of denial, and pushed people dying of AIDS to the fringes of society.

AIDS Ministry in the Context of the African Experience
While AIDS ministry in the African Church is infused with spirit and energy, it also faces the formidable challenges that come from ministering in a region profoundly stricken by extreme poverty. Many Africans living with AIDS and their families lack basic human needs like a regular supply of food, potable water, and security from violence. Without proper nutrition, someone sick with AIDS cannot expect to survive long, even when given the best possible treatments.

Additionally, despite the tireless efforts of many, poverty and other factors of economic distribution make it difficult for many healthcare initiatives to provide the type and quality of care that the level of need in Africa demands. Often care providers are forced to improvise with the resources they have available. In an America magazine article from 2003, Sr. Margaret Farley, who is involved with Sister to Sister, an effort launched by women religious in Africa and the US to address the African AIDS pandemic, recalls the inadequacy of two hospices she visited in Ethiopia, one of which “could offer only a few vitamins, and at the other all they had on hand was a watered-down form of aspirin.”

Many healthcare institutions in Africa also lack the requisite drugs to prevent the transmission of the virus from mother to child during birth. However, even when these drugs are available to prevent transmission at childbirth, most HIV positive mothers must nurse their infant because baby formula is too expensive, likely infecting the child later through their breast milk. As a result, 1,400 newborns in Africa are infected each day, according to UN estimates.

Women have been hit particularly hard by the African AIDS crisis. It is estimated that 60 percent of new infections in Africa happen in women, and the rate of infection among young women and girls is 2.5 times that of their male counterparts. A prenatal clinic in Lusaka, Zambia reports that 35 percent of the pregnant women who come in are HIV positive. Because of their economic dependence, many African women have few available avenues of recourse when their husbands are unfaithful and thus put them at risk of contracting the disease. Additionally, when a male breadwinner dies or disappears, women are often forced to contemplate the risk of prostitution, a service for which there seems to be a stable demand, as the only viable way of providing for themselves and their families.

In response to this reality, many of the Church’s efforts at combating AIDS focus on economically empowering women. Many local Catholic efforts work to provide women opportunities for income generating activities, like making small handicrafts or food products for sale, to grant them better routes to fulfill their financial needs. They also teach basic leadership and money management skills, and provide basic literacy and other educational instruction to both adult women and girls.

The children of Africa have also been deeply affected by the AIDS pandemic. Over 12 million children have lost at least one parent to the disease, and the number of orphans is rapidly growing. In the country of South Africa alone, there are an estimated 700,000 orphans. Remembering Christ’s call to “let the children come to me,” the Church has reached out to care for these orphans. As director of the Education for Life program in the Eldoret Diocese of Kenya, Sister Helen O’Regan follows more than 50 orphans from various parishes in or near Eldoret, whose needs range from food to shoes to school supplies. She often has to turn to outside fund raising efforts to support these needs.

Many orphans also contracted the virus during birth or nursing, leaving them in a very precarious state. In 1992, Jesuit Fr. Angelo D’Agostino started a home for 70 of these orphans with AIDS in Kenya. “AIDS orphans have never been fully accepted,” says Fr. D’Agostino in an article in Catholic Insight magazine (link below). “That is why I started Nyumbani Children’s Home. I wanted to make them feel part of humanity.” As part of his advocacy for the children he serves, Fr. D’Agostino worked to overturn a discriminatory law that allowed public schools to deny enrollment to children who were HIV positive.

Clearly the Church’s efforts to respond to the AIDS pandemic in Africa are both serious and sincere, still many observers from the global north cite the church’s prohibition on condom use as a factor in the continued spread of the disease in Africa. The next installment in this series will look at this controversy surrounding condom use in the Church’s response to AIDS, as well examining other behavioral change approaches, like the promotion of abstinence and fidelity.

Condom Controversy
CNS PhotoThough the Catholic Church provides over a quarter of the total care for people with AIDS worldwide, detractors continually and vocally assert that, due to its teaching prohibiting all artificial contraception, condoms included, the Church is an enemy of efforts to counter AIDS. These critiques, however, commonly overestimate the effect condom use alone can have on curbing the spread of the virus in Africa. As explained in part one of this series, economic factors are the root cause of the AIDS crisis; yet for many people in economically advanced nations (home to the most passionate of the Church’s detractors), such factors are overshadowed by the focus on condoms. This may be due to the fact that Africa’s economic plight, directly or indirectly indicts us all. Such criticisms also conspicuously fail to recognize the integral role the promotion of other behavioral changes, like sexual monogamy or abstinence play in combating the spread of AIDS. They also fail to take into account the nuanced approach to advocating condom use as a last resort by an increasing number of Church officials in the global South.

Any examination of the condom controversy at some point needs to address the issue on the level of simple logic.In Africa, most of the spread of the virus happens through pre- or extra-marital relations. Since those engaging in such relationships are clearly not following the Church’s fundamental teaching about the sanctity of marriage, it is doubtful they place much importance on secondary teachings regarding sexuality like those concerning contraception. Certainly the Church’s teaching alone would not be enough to dissuade them from condom use.

The effects of efforts aimed at inducing other sexual behavioral changes are often overlooked in discussions focusing exclusively on condom use. A telling example is the case of Uganda, which, through a concerted governmental effort against the spread of the disease, was able to reduce the prevalence of HIV/AIDS in its country by over 65 percent between 1991 and 2001. The US Agency for International Development (USAID) and other researchers examining this astounding decline credit the government’s strong and successful promotion of behavioral changes like sexual fidelity and abstinence among youths as the main forces behind the decrease in AIDS in Uganda. Increased and more effective condom use was, at best, only a secondary factor in the decline, according to researchers.

Fr. Stefan Hippler, who works in Cape Town, South Africa, agreed that condoms are sometimes permissible in the context of the AIDS pandemic. “I have seen too many people dying,” he told the Post. “We are advocating life, and here is the life of people at stake.”

Data indicates that between 1989 and 1995, there was a decline of over 50 percent in the proportion of both men and women in Uganda who reported engaging in casual sex during the previous year. Additionally, sexual activity among Ugandan youth sharply decreased. In 1994 over 60 percent of boys and over 20 percent of girls ages 13 to 16 reported having had sex; by 2001 those proportions were approximately five and two percent, respectively, for the same age cohort. Compared with men from similar countries that did not experience such dramatic improvements in AIDS incidence, in the 1990s Ugandan men “were less likely to have ever had sex (in the 15-19-year-old range), more likely to be married and keep sex within the marriage, and less likely to have multiple partners, particularly if never married,” according to USAID.

These behavioral changes were achieved through decentralized, community-based partnerships between teachers, religious pastors, social workers, and other local leaders. An interesting footnote to this success story is that, during part of the period of declining AIDS incidence, a Catholic Bishop was chairperson of the national Uganda AIDS Commission.

Despite evidence of their effectiveness, strategies like those that were used to reduce the spread of the disease in Uganda, do not always sit well with AIDS activists in the US and other developed countries, in part because, at least implicitly, they are based on the idea of a normative sexual morality. However, as South African Bishop Buti Tlhagale, wrote in an America magazine article in 2000, “Most religious traditions uphold and advocate the virtues of abstinence, self-control and sacrifice. These virtues are not archaic. Indeed, they may even reduce the incidence of the killer disease.”

The Greater Evil?
The effectiveness of the promotion of abstinence and monogamy notwithstanding, some Catholic organizations support condoms as a last resort in situations when high-risk behavior cannot be dissuaded or avoided. This would be particularly relevant for groups facing a greater risk of contracting the virus, like women forced into prostitution. Thus, while not denying the Church’s traditional moral concerns about contraception, employing condoms in a risk reduction approach might prevent the greater evil of spreading the deadly virus.

Recent reports indicate that many Catholic AIDS prevention efforts in Africa have already adopted this approach. In April, the Washington Post profiled Sr. Christine Jacob, who runs a health clinic in rural South Africa and sometimes counsels patients to use condoms. While Jacob would never do so to teenagers – “Our biggest fear is …by saying ‘condomize,’ it’s giving license,” she confessed – but if confronted with a prostitute or someone in a similarly tough situation, she would advise them to use condoms. Fr. Stefan Hippler, who works in Cape Town, South Africa, concurred that condoms are sometimes permissible in the context of the AIDS pandemic. “I have seen too many people dying,” he told the Post. “We are advocating life, and here is the life of people at stake.”

Last year the Catholic Agency for Overseas Development (CAFOD) issued paper on AIDS in Africa reading, “Any strategy that enables a person to move from a higher-risk towards the lower end of the continuum, CAFOD believes, is a valid risk reduction strategy.”

While the fundamental aspects of the Church’s teaching on artificial contraceptives in normal circumstances are unlikely to change, there appears to be growing consent by Church leaders that, under certain conditions, condom use might be permissible in countries ravaged by AIDS. In February, Vatican official Cardinal Georges Cottier publicly stated his opinion that in certain circumstances condom use “could be considered legitimate” because “it diminishes the danger of contagion.” An increasing number of bishops and Vatican curialists are adopting similar nuanced views regarding condom use in certain situations.

While sex outside of marriage violates the Sixth Commandment against adultery, Msgr. Rodriguez Luño feels that, “Infecting someone with AIDS would also mean sinning against the Fifth Commandment – ‘you shall not kill’ […] Condoms would diminish that danger.”

Such complex positions, however, are often difficult to express. Msgr. Angel Rodriguez Luño, a consultant to the Congregation on the Doctrine of the Faith, explained to the Washington Post; “The problem is that anytime we try to give a nuanced response, we see headlines that say, ‘Vatican approves condoms.’ The issue is more complicated than that … We cannot tell a classroom of 16-year-olds they should use condoms. But if we are dealing with someone or a situation in which clearly persons are going to act in harmful ways, say, a prostitute who is going to continue her activities, then one might say, ‘Stop. But if you are not going to, at least do this.'”

While sex outside of marriage violates the Sixth Commandment against adultery, Rodriguez Luño feels that, “Infecting someone with AIDS would also mean sinning against the Fifth Commandment – ‘you shall not kill’ … Condoms would diminish that danger.”

While officials like Rodriguez Luño, in approaching the debate in a straightforward manner, honestly recognize that condoms can reduce, though not eliminate, the risk of contracting the virus, others in the Church, unfortunately, have tried to obscure this fact by propagating false and unsubstantiated claims about the effectiveness of condoms. Cardinal Alfonso Lopez Trujillo, head of the Pontifical Council for the Family, stated in a 2003 TV interview that the HIV virus is small enough to “easily pass through” the pores in latex condoms – a claim deemed spurious by the medical and scientific community. Additionally, while condoms are far from 100 percent effective and can, perhaps, contribute to a false sense of security, bishops in some countries have wrong-headedly backed efforts at placing warning labels on condoms that seem to exaggerate the level of risk associated with their usage.

Attempts at obscuring the medical realities about condoms are no better than arguments that exaggerate the effectiveness of condoms in curbing the spread of the disease. Moreover, they undermine the unique and important wisdom that the Church brings to the table in discussions of the AIDS pandemic.

At all levels, the Church has worked tirelessly to address the poverty that is at the root of the African AIDS pandemic. It has spoken clearly and consistently in condemnation of the unjust effects of neoliberalism, and Catholics around the world have animated the social movements seeking third world debt cancellation and the creation of a more just economy. On the ground in Africa, Catholic organizations are caring for the sick, the dying, and the orphaned. They are joining community-based efforts against the spread of the disease, and are bringing to these efforts often overlooked approaches promoting chastity and fidelity that have proven effective. There is also a growing set of Church officials directly confronted with such dilemmas in Africa and elsewhere in the global South who support condom use as a risk reduction method as a last resort to avoid the greater evil of further infection.

Sadly, the only thing that remains clear in the face of this crisis is that there are no easy solutions to the AIDS pandemic in Africa. Claiming over 6,000 lives each day, the African AIDS pandemic continues to present a moral indictment against all humanity. How can one truthfully claim to be a disciple of Jesus Christ and not be moved to act against this human tragedy? “I don’t care about the condoms yes, condoms no, debate,” said Cardinal Javier Lozano Barragan of Mexico at a news conference last December announcing his appointment to head a Vatican initiative against AIDS worldwide. “What concerns me is that these people are dying and I have to help them.”