Cardinal's words may indicate moral trickle-up from health workers

By STACY MEICHTRY

Say the words “Catholic church” and “AIDS,” and most people automatically think “condoms.” In the media and on the street, the Catholic church’s response to the global HIV/AIDS crisis is identified with a resounding “No” to the device many public health experts see as an essential element of any anti-AIDS strategy.

This perception led many in the media in January to cast Jesuit Fr. Juan Antonio Martínez Camino, secretary general for the Spanish Bishop’s Conference, as an outspoken condom proponent -- a role, they said, that put him at odds with the Vatican.

Following a Jan. 18 meeting with Spain’s health minister Elena Salgado, Martínez told reporters in Madrid that “the time has come for a joint strategy in the prevention of such a tragic pandemic as AIDS, and contraception has a place in the context of the integral and global prevention of AIDS.” A day later, however, the conference issued a statement indicating that Martínez’s comments were not to be interpreted as a challenge to church teaching.

As it turns out, this is one of those areas where “church teaching” is not quite as clear as it seems.

Martínez was backing a health program known as ABC, which stands for “Abstinence, Be faithful and Condoms,” and promotes monogamy as the best way to prevent the spread of AIDS. In cautiously supporting the program, Martínez joined other clerics who believe there are limited circumstances in which condom use can be justified without endorsing contraception.

Exactly what these circumstances might be, however, is a matter of interpretation. So far the onus of identifying social contexts that obviate the condom ban has fallen to the church’s network of health care workers.

Through dioceses, religious orders, lay movements and individuals, the Catholic church runs a prodigious network of hospices, orphanages, clinics and think tanks. In one hard-to-verify but telling statistic, the Pontifical Council for Health Pastoral Care asserts that 27 percent of all AIDS relief worldwide is administered by the Catholic church.

Facing disparate resources and unpredictable working conditions, segments of the network are no longer waiting for instruction. Instead they’ve taken it upon themselves to hammer out moral criteria for dealing with condoms. And, as the Martínez flap demonstrates, their ideas have begun to trickle up.

In 2003, according to statistics from the U.N. World Health Organization, 35.7 million adults and 2.1 million children were living with HIV/AIDS. This is more than 50 percent higher than the figures for 1991. In sub-Saharan Africa alone, there are 25 million adults and children living with HIV/AIDS (7.5 percent of the total population). In 2003, there were 2.2 million deaths of adults and children from AIDS in Africa.

On the frontlines, Catholic relief workers have emerged as an authoritative voice. They have drawn the attention of their secular counterparts for breaking ground in rural communities where the pandemic has hit hardest.

“I have to say that as I travel around Africa, the work of the Catholic church is extremely impressive,” Stephen Lewis, the U.N. envoy to Africa, said in an interview with NCR.

The condom ban, Lewis said, may be definitive in Rome, but it is an open question on the ground. “In my experience, without naming names, many of the grass-roots Catholic leadership do not pay attention to that side of church teaching. They just don’t honor it. Condoms are available.”

The teaching Lewis has in mind is especially associated with the Pontifical Council for the Family, which last year declared condoms unsafe as a form of AIDS prevention. In an interview with the BBC, council president Cardinal Alfonso López Trujillo, a Colombian, claimed the HIV virus is small enough to “easily pass through” latex. López also asserted that condoms encourage promiscuity, which he deemed among the root causes of the pandemic.

But church thinking tends to vary according to who is doing the talking. The Pontifical Council for Health Pastoral Care, for example, has taken a softer line -- one that closely reflects the realities facing the health care workers it advises.

Cardinal Javier Lozano Barragán, a Mexican who heads the health council, told NCR in a recent interview that he opposes the distribution of condoms, because he believes it institutionalizes promiscuity. On the other hand, he finds the use of condoms acceptable when abstinence is not an option.

“If an infected husband wants to have sex with his wife who isn’t infected, then she must defend herself by whatever means necessary,” he said.

This position, Barragán said, is consistent with the tenets of Catholic moral theology, which teaches that acts of self-defense can extend to killing in order to not be killed. “If a wife can defend herself from having sex by whatever means necessary, why not with a condom?” he said.

Barragán said this belief informs his decisions as head of the health care council, but added that his views are personal and that he does not speak for Pope John Paul II. “The Holy Father has never spoken explicitly on the subject,” Barragán said.

Redemptorist Fr. Brian Johnstone, a moral theologian who teaches at Rome’s prestigious Alphonsian Academy, told NCR in mid-November that with some nuance, Barragán’s position would be widely shared by many Catholic moralists. While the Catholic church is unambiguously opposed to contraception as a matter of principle, Johnstone said, there is no definitive position on whether condoms could be seen in some cases as a “lesser evil” to prevent the spread of disease.

The absence of a final pronouncement has provided leeway for relief agencies to stake out different positions.

Ugandan President Yoweri Museveni roiled the U.N. AIDS conference in Bangkok, Thailand, last July when he attributed Uganda’s success at slashing HIV infection rates to its promotion of abstinence and monogamy. Uganda, credited with pioneering the ABC program, claims a drop in HIV infections from 30 percent in the 1990s to about 6 percent in 2003. As far as Museveni was concerned, point “C” played a limited role, leading him to declare, “The principle of condoms is not the ultimate solution.”

The Catholic Agency for Overseas Development, which operates under the aegis of the Bishops’ Conference of England and Wales, challenged Museveni. In a policy paper, CAFOD attributed Uganda’s success to a holistic strategy that included condoms as well as legislation outlawing gender violence and sexual coercion. More controversially, the paper challenged the church’s dogmatic ban on condoms, striking directly at its rationale -- that promiscuity is primarily to blame for the spread of AIDS.

Although the CAFOD paper echoes Barragán and other senior clerics such as Cardinal Godfried Daneels of Belgium, it is unclear if its policies will gain official backing. Following the Bangkok conference, Cardinal Cormac Murphy-O’Connor of England characterized the use of condoms as a “moral obligation” in certain circumstances. But a spokesperson stressed that Murphy-O’Connor had not seen the CAFOD report at the time of this interview.

Barragán said many Catholic agencies make no effort to conceal their condom advocacy. On a recent visit to Asia, Barragán visited several church-run clinics with posters instructing on condom usage hanging on the walls. “I told them ‘Look, this you can’t do,’ ” he said.

The Holy See hopes to augment Catholic anti-AIDS efforts by launching its own health foundation, called the Good Samaritan Fund. Barragán, who will oversee the foundation, said its purpose is to direct AIDS funding though local dioceses without government mediation. Streamlining the distribution chain, he said, should limit misappropriation by bureaucrats.

Collaboration with secular funders, however, could increase the church’s vulnerability to condom advocacy. As a spokesman for the South African Bishops’ Conference’s AIDS treatment campaign told NCR, increased collaboration with doctors and other health care professionals has made it hard to keep condoms out of their facilities.

“The more people you involve, the more opinions you get,” he said.

Rukia Cornelius, a coordinator for the Treatment Action Campaign, a nongovernmental organization collaborating with the South African Bishops’ Conference to boost the number of AIDS patients receiving anti-retroviral medications, told NCR that the campaign has not scaled back its advocacy of condoms. Ever since the Council for the Family fired off its salvo, however, this has become a liability to its relations with the church.

Barragán said he is aware of the ethical challenges, but believes the church’s interests are best served by raising its profile in the health community rather than recoiling from it. This rationale applies in particular to the role he envisions for the Good Samaritan Fund.

“This fund can be a negotiator as well as a collaborator with the United Nations Global Fund,” he said. “Our foundation could collaborate with the Global Fund, but if the Global Fund doesn’t want to collaborate with us, it doesn’t matter. We will take the route appropriate for the Catholic church.”

Whatever route is taken, church leaders might think twice before opting to go it alone.

“The church has said, ‘People are dying, we have money, and we can use this money to put people on treatment,’ ” Cornelius said. “But setting up a program is no easy thing. You have to find the drugs, make sure they’re cleared by regulators; you have to foster treatment literacy. What do religious leaders know about putting people on treatment?”

The consensus among many observers is that the church functions best as a mediator between health care organizations and patients in rural areas, where the disease has been most virulent and infrastructure is at its worst. There, mistrust of modern medicine runs high. And some even argue that rural populations view the church as a trustworthy interlocutor because it opposes condoms.

“Actually, the religious community is quite mainstream in its hesitancy to support condom use,” said Nancy Snauwart, who heads the UNAIDS mission to Nigeria in Abuja.

Snauwart is currently pushing for more coordination between UNAIDS and the country’s religious community, which she estimates provides 40 percent of AIDS care in rural Nigeria. Many have adopted Uganda’s ABC campaign. But Snauwart said the strategy has faltered because religious leaders do not enjoy the same support from the Nigerian government that they’ve had in Uganda.

That is the situation confronting Benedictine Sr. Priscilla Dlamini at the Holy Cross AIDS Hospice in Ginginddlovu, South Africa. She has neither government funding, nor the financial support of her diocese. She has nevertheless expanded her operations over a 10-mile radius by recruiting a small army of housewives to administer home care in the villages. Back at the hospice, she runs a daycare center for the nearly 1,200 children that have been orphaned by the disease.

The question she keeps coming back to doesn’t have anything to do with condom use, and it is a reminder that the debate over condoms is perhaps a fatal distraction.

“What if I die?” she asked. “Who’s left to care for these people?”

Stacy Meichtry is a freelance journalist based in Rome.

National Catholic Reporter, February 25, 2005