THEOLOGICAL CHALLENGES POSED BY THE GLOBAL
PANDEMIC OF HIV/AIDS
A Reflection by Rev. Robert J. Vitillo, of Caritas
Internationalis, with the Theological Study Group on HIV/AIDS, Boston
College
23 March 1994.
First of all, I would like to thank Fr. Jon Fuller and all of you
for the kind invitation to share concerns and reflections on the global
pandemic of HIV/AIDS with you this afternoon. I am keenly aware that I come as
a stranger to your group and thus must labor under several disadvantages -- for
both you and me. I have not been present for any of your previous discussions
and thus apologize if I raise issues which you have previously discussed, or
better yet have even resolved! Although I majored in theology during my
undergraduate studies and then pursued graduate studies in the field before
ordination, I am not currently working in the field and thus must beg your
indulgence for any inaccurate or outdated terminology or concepts which I might
propose. With those reservations aside, however, I feel deeply honored and
privileged to share with you the questions, concerns, frustrations, and
expectations related to theological reflection which have been relayed to me by
persons from various parts of the world who are either living with this
condition or who are working on a day-to-day basis in providing HIV/AIDS
education and advocacy or care to those affected by the pandemic.
Perhaps I might begin by offering a brief word about my
organizations involvement in the field of HIV/AIDS. The organization for
which I work is Caritas Internationalis, which is a confederation of 125
national member organizations which have been given the mandate by the
Episcopal Conference or national hierarchy to coordinate the social service and
development work of the Catholic Church in their respective countries. At a
General Assembly held in Rome in 1987, the member organizations first addressed
the global implications of HIV/AIDS in a plenary discussion; the reactions of
the participants might best be described as alarmed and confused. Some denied
that AIDS was a problem even in countries where the impact was quite evident.
Others expressed encountering difficulties with Church authorities by entering
into AIDS education or service. Still others could not see how church-related
sociopastoral organizations could avoid entering such work. At the end of the
discussion, there seemed to be a resolute -- if somewhat uneasy -- consensus
among the Caritas member organizations that HIV/AIDS should be selected as one
of the priority themes of reflection and action for the Confederation during
its 1987-1988 mandate. This same resolution was reaffirmed in a much more
positive manner at the 1991 Caritas Internationalis General Assembly.
Since 1987, I am pleased to report that Caritas Internationalis
has attempted to mobilize a non-judgemental and compassionate service response
to the challenges posed by this pandemic in the following manner.
by sponsoring educational seminars on the global, regional and
national levels (primary target audiences are church leaders -- bishops,
clergy, religious men and women, lay catechists, and those engaged in
church-related health and social service activities;
by establishing a Working Group of Experts who could provide
consultation and guidance to those interested in organizing church-related
HIV/AIDS services in various parts of the world. I am happy to report here that
Fr. Jon Fuller has been serving as the North American representative on the
Working Groups since 1991.
By seeking funding and professional expertise to support some 12
HIV/AIDS projects in Africa, Asia, Eastern and Central Europe, Latin America
and the Pacific.
By organising for the exchange of experiences among those
actively engaged in such ministry as well as those who are contemplating entry
into the field.
The reflections which I would like to share with you this
afternoon might be divided into three main areas.
Moral/Ethical Issues Related to
HIV/AIDS Fundamental Issues Ecclesiological
Issues
1. Moral/Ethical Issues Related to HIV/AIDS
Rather than launching directly into some of the well-debated
ethical issues related to prevention, I would prefer to begin with those
related to distributive justice, since I believe that they underlie much of our
reflection and action in this field. I am frequently challenged by colleagues
in the Caritas network who ask why we should expend so much time and so many
resources to respond to HIV/AIDS when the world continues to be plagued by a
myriad of other health and development crises. Thus the first distributive
justice question for me is whether this pandemic warrants so much attention,
concern and activity.
While I do not wish in any way to detract from other
health-related, social and development endeavors, I do believe that HIV/AIDS is
rather unique in its nature. Some reasons underlying my belief are the
following:
HIV does not have a well-defined geographically limited spread
as do many other epidemics. It has already spread to every corner of the earth,
to every age group, every level of society and to persons of all sexual
orientations.
HIV is not self-exhausting as are other epidemics; it involves
an incubation period of ten to fifteen years or more during which the infected
person neither notices or reveals any evidence of disease and yet remains
capable of transmitting the virus to others;
The transmission of HIV involves substances and activities which
are vital to human existence i.e., blood and sexual
intercourse.
The World Health Organization estimates regarding the present-day
epidemiological evolution of this disease are already quite convincing:
more than 14.5 million people worldwide are infected with
HIV;
some 3 million people have already advanced to the stage of
serious illness, or AIDS;
some 5 out of every 11 HIV-infected persons in the world are
women;
more than 1 million babies have been infected with the
virus;
the epidemic is presently spreading in South and Southeast Asia
at a pace which is similar to that which took place in sub-Saharan Africa
during the 1980s.
The experts tell us that the numbers of persons infected by HIV
will continue to grow at a frightening rate, maybe in the range of 30 to 110
million by the year 2000, and may even reach 1 billion within the first decades
of the next millennium. The number of persons living with AIDS is projected at
10 to 24 million by 2000. By that same year, it is expected that at least 10
million children will be orphaned as a result of AIDS deaths of one or both of
their parents and another 10 million children will themselves be infected by
HIV.
Perhaps the most compelling statistics which I have recently seen
relate to the number of life years saved by preventing the occurrence of one
single case of the following diseases:
DISCOUNTED HEALTHY LIFE YEARS SAVED PER CASE,
VARIOUS DISEASES, AFRICA |
DISEASE |
LIFE YEARS SAVED |
Gastroenteritis |
1.4 |
Pneumonia (adults) |
2.0 |
Malaria |
3.2 |
Syphilis |
3.8 |
Measles |
5.0 |
Tuberculosis |
7.1 |
Pneumonia (children) |
11.2 |
HIV infection |
19.2 |
Neonatal Tetanus |
22.7 |
Source: Mead Over and Peter Piot (1992),
HIV Infection and Sexually Transmitted Diseases in D. Jamison and
H. Moseley (eds.) Disease, Control Priorities in Developing Countries:
New York, Oxford University Press. |
These statistics do not even begin to tell the story of the
Hidden Costs of AIDS which will pose unheralded challenges to the
Churchs diaconal apostolate. These include the following:
the need to restabilize the economic, health and social support
base at the local and even the national levels in many developing countries
where large numbers of young and middle-aged adults (i.e., the most
economically productive members of the society) are becoming ill and dying of
AIDS;
the care of elderly persons who are suddenly surviving their
adult children and thus unable to rely on the traditional systems of family
care;
the nurturing and education of thousands of children whose
parents have either died or have become severely incapacitated because of
AIDS;
Against such a sobering scenario, I would like to raise the
following distributive justice concerns which are, in my opinion, begging for
serious theological reflection.
The World Health Organization estimates that key HIV prevention
programs could be implemented successfully in developing countries for between
$1.5 billion and 2.9 billion a year. This represents only 1/20 of the amount
spent on Operation Desert Storm which cost the sum of $49 billion. I recall a
fair amount of theological debate on whether Desert Storm conformed to the Just
War Guidelines; but I have seen very little theological attention being focused
on the equitable share of government and private resources which should be
directed to HIV prevention.
When taking into account the meager funds which are expended on
HIV/AIDS services, we are confronted once again with many inequities. Thus we
note that, during 1992, 80% of HIV-infected people live in developing
countries, while 95% of the (US) $7 billion spent last year on AIDS education,
care and research was expended in the industrialized world.
Although four developing countries have been called upon to
offer subjects for the first large-scale human trials of potential HIV vaccines
(i.e., Brazil, Rwanda, Thailand, and Uganda), there is no guarantee that the
residents of these countries will be availed of such vaccines on a widespread
and affordable basis once they have been perfected. Thus I will never forget
the haunting challenge posed by Ugandas Minister of Health at the 1992
International Conference on AIDS which was held in Amsterdam:
The people of Uganda are offering themselves as subjects
in the vaccine trials for the good of all humanity; do not forget us when the
vaccines arrive in the marketplace! |
I do not wish to leave the impression that these distributive
justice dilemmas are restricted to the macro level. Allow me to offer some very
specific incidents in which my Caritas colleagues have been involved:
Our network has been supplying rapid HIV-antibody test supplies
and equipment to mostly rural-based, church-related health services which are
called upon to administer blood or blood products but have not benefited from
the testing facilities provided by governments or the World Health
Organization, which are often concentrated in national and provincial capitals
and never arrive in the more isolated areas of developing countries. We had
negotiated a special rate in the more isolated areas of developing countries.
We had negotiated a special rate with one prominent pharmaceutical company for
HIV-1 Antibody Test Kits. When that same company developed a test which could
detect both HIV-1 and HIV-2 antibodies, they raised their price from $1 to $3
per test kit. We approached the company and explained that the new price range
made it extremely difficult for us to purchase large supplies for our partners
in the developing world. The response which we received from company officials
was that the test had been developed for the residents of Northern, or rich,
countries, not for those in the South.
Last week I visited an AIDS Counseling and Service Center in
Ethiopia. There I was shown the empty medicine cabinets by the nurses; they
have been unable to obtain desperately needed T.B. medication for their
clients. They have only a five-week supply left and know that, if they begin
new patients on this therapy today, they may not have enough medication left to
assure a full course of treatment. All their appeals to governmental and
private funding sources have so far fallen on deaf ears.
There are indeed some other ethical/moral issues which I feel
compelled to mention. The first set of such issues relate to PERSISTENT AND
WIDESPREAD DISCRIMINATION AGAINST PERSONS LIVING WITH HIV/AIDS. In almost every
country which I have visited in recent years, such discrimination is rampant --
even in church-based pastoral, health and social services. One bishop asked me
in full assembly with his brother bishops from an entire continental region how
he could instruct his priests to spot a person with AIDS so that
they could avoid coming into contact with such persons. I cannot adequately
describe the disappointment of laypersons and religious alike, on almost every
continent, with the clergy who refuse to visit or attend to the sacramental
needs of persons living with the disease. Some pastors have even ostracized the
families of such persons and of others in the community who are considered
sinful. At times, priests have forced persons living with AIDS to
publicly disclose their sins or to pay special taxes in order to
remain as members of the local parish community and thus to qualify for a
Christian burial.
The experiences in this area do not always remain negative. I
recall specifically the medical director of a well-respected Catholic hospital
in Southeast Asia who steadfastly refused to admit patients suffering with
AIDS. After attending a Caritas-sponsored HIV/AIDS seminar and after being
confronted with this policy, on both medical and ethical grounds, he not only
reversed his previous decisions but also began a comprehensive HIV/AIDS
training program for his entire staff.
The main challenge I wish to pose here is for theologians to link
HIV/AIDS discrimination issues with other struggles for justice and with
necessary condemnations of discrimination in other areas of social life. The
proof of such a need lies in the fact that the very members of society who are
most subjected to other structural injustices in society are the most
vulnerable to the spread of the HIV/AIDS virus. Thus we see that the pandemic
is most disseminated among the poorest and most marginalized in society. We
know, for example, that women (especially very young women) are more
biologically vulnerable to contacting HIV, have less control over their own
sexual health and activity as well as over the sexual activity of their
parents, and are often blamed as vectors of HIV even when the entry
of the virus into the family circle may have indeed come from the marital
infidelity of their husbands. When I have approached certain women theologians
in the past with regard to a request to reflect on these HIV-related issues
which are so fundamental to the survival of women in present-day society, I
have often been rebuffed with the excuse that they are too busy with the
struggle for justice and equality.
Another ethical issue which I am sure is not unfamiliar to you
relates to HIV prevention education and specifically focuses on information
related to the use of the condom with sexual activity (especially when one
partner is HIV-infected and the other is not) and to the clean
needle campaign with regard to injecting drug use. My personal opinion is
that too much theological energy has already been dedicated to this issue; my
experience in the field tells me, however, that many church-related service
workers are still searching for accurate, practical and reality-based debate on
this topic.
I cannot emphasize enough the need for accurate information on
which to base our ethical discussions. There are indeed many persistent myths
related to HIV prevention. Time and again, I have met religious leaders who are
convinced that condoms (even when properly and consistently used) are not
effective in preventing the spread of HIV, even though scientific evidence has
proved this premise wrong.
There is also the myth that information about preventive
techniques, especially among young people, will simply encourage early sexual
activity or injecting drug use. Once again, the scientific evidence proves this
assertion wrong. Perhaps the most compelling evidence in this regard was
presented at the 1993 International Conference on AIDS in Berlin which reported
studies demonstrated that well-designed school education about safer sex leads
to more responsible sex, a delay in first intercourse, and fewer teenage
pregnancies. Dr. Anke Erhardt (Psychiatric Institute, New York), for example,
reported that age at first intercourse is similar in Europe and USA but,
because sex education in European countries is better than in the USA, the
rates of teenage pregnancy are dramatically different: the UK rate is less than
half that of USA, and the Netherlands is ten times lower than in USA.
Here I must insist that the theological discussions need to be
reality-based. In one seminar which I conducted in Asia, a very pious religious
sister maintained that if she were married and her husband were infected with
HIV there would be no question of condom use because, if her husband really
loved her, he would not want to have sex with her. A married woman in the
audience felt compelled to disagree: If my husband were infected with
HIV, we would need to continue our sexual relationship in order to offer each
other the mutual support which we would both so desperately need!
Finally, there is a need for practically-oriented ethical
reflection on prevention. I recently visited a country which is just emerging
from a 35-year-long and bitter struggle for independence from its neighbor to
the South. Many of the returning and recently deployed military (which included
both men and women) are HIV-infected and are beginning to develop the systems
of AIDS. I was informed by one church worker there that the religious in the
country had written to the bishops and insisted that they could no longer stand
idly by and watch people die of AIDS. They begged the bishops to offer some
ethical guidelines for both care and prevention. The response of the bishops
was to send a canon lawyer to a meeting of the Conference of Religious. This
canonist cited the Code of Canon Law but revealed no practical knowledge of the
situations faced by persons living with HIV/AIDS, by their loved ones, or by
those who wish to be of service in response to this pandemic.
The last ethical issue which I find especially delicate but
necessary to mention involved the need to DENOUNCE SEXUAL ABUSE WHICH HAS
ARISEN AS A SPECIFIC RESULT OF HIV/AIDS. In many parts of the world, men have
decreased their reliance on commercial sex workers because of their fear of
contracting HIV from such persons (no one ever seems ready to admit that many
commercial sex workers are themselves infected by their clients). As a result
of this widespread fear, many men (and some women) have turned to young (and
therefore presumably uninfected) girls (and boys) for sexual favors. Religious
women have also been targeted by such men, especially by clergy who may have
previously frequented prostitutes. I myself have heard the tragic stories of
religious women who were forced to have sex with the local priest or with a
spiritual counselor who insisted that this activity was good for
the both of them. Frequently, attempts to raise these issues with local and
international Church authorities have met with deaf ears. In North America and
in some parts of Europe, our Church is already reeling under the pedophilia
scandals. How long will it take for this same institutional Church to become
sensitive to these new abuses which are resulting from the pandemic?
2. FUNDAMENTAL ISSUES
I am convinced that the pandemic of HIV/AIDS will force
theologians to grapple more seriously with the fundamental theological premises
related to human nature, and, more specifically, related to human sexuality.
Notice that I have placed the need for theological reflection related to
sexuality within the fundamental rather than the moral order. It seems to me
that theologians have not yet faced the daunting task of elaborating a
substantive theology of human sexuality as a creation of God who willed this to
be such a strong, dominant, and constitutive element of human nature. Nor have
we sufficiently considered how Gods grace has elevated the totality of
the human person (including his/her sexuality) to a level which is different
from the rest of animal or plant life.
All too often, I have met Christians -- clergy, religious and
laypersons -- who have been scarred by our Churchs refusal to seriously
acknowledge the sexual side of their being. I was greatly impressed by the
courage and stamina of one Italian woman religious who worked for many years in
Mozambique. She feared neither the government military nor the rebels and
confronted them openly when she noticed any unjust treatment of the civilian
population. When this same woman participated in a national-level seminar on
HIV/AIDS, however, she became visibly shaken and uncomfortable each time there
was any discussion of sexuality. After some open and frank debate within the
group, she finally admitted that she had long harbored the idea that any sexual
behavior -- even among married couples -- was somehow selfish and base and
shared her previous belief that only celibates could fully follow the Lord. She
thanked the group for assisting her to develop a more mature and integrated
vision of her own life and sexuality.
Too long have we assigned sexuality to a deep, dark secret in our
Church. One Latin American bishop stated publicly during a HIV/AIDS seminar
which I attended that there were only two things which he refused to discuss
with his priests -- their financial condition and their sexual behavior (he did
not use such a refined term!). I believe that it is indeed time to discuss
sexuality with priests, religious and laypersons alike -- not in order to
denigrate the value and gifts and choices of celibacy or of faithfulness in
marriage, but rather to assure a more healthy and integrated personal life no
matter what ones particular vocation in life might be.
Another challenge for fundamental theologians is for them to
assist the citizens of the world to delve into the meaning, at this particular
time in our world history, of this pandemic and of the personal suffering which
it entails. Most unfortunately, some church leaders (including some among the
Catholic hierarchy) have claimed that this pandemic is Gods punishment on
those who are considered to be unnatural, or abnormal, or sinful. Those church
leaders may have been small in number, but their voices have been heard far and
wide. Some still persist in this negative message about Gods relationship
with human persons. Last year, I traveled to an Asian country to facilitate a
workshop for the bishops there during one of their regular Episcopal conference
meetings. Upon my arrival, I was pursued by a prominent archbishop who began to
question me about whether I believed that AIDS could be a punishment from God
for those who are promiscuous. The archbishop was not satisfied with my
negative response and continued the same line of questioning during a plenary
presentation the next morning. Have you not read the Old Testament where
God does such things? he asked. I replied that I had indeed read the Old
Testament but also had read and reflected on the New Testament in which Jesus
brought a message of acceptance and forgiveness. The archbishop was not one to
concede and thus continued to stress his point that promiscuous people deserved
to be punished. Finally, I reminded him that many people who in no way could be
considered promiscuous also had contracted HIV and I simply could not put my
faith and hope in a capricious, vindictive God. During the coffee break, many
of his fellow bishops complimented me for my response, but none of them had
been willing to support me during the discussion which had been held
earlier.
There are indeed many persons living with HIV/AIDS and those who
care for them who have found deep meaning and redemption in the suffering
associated with this disease. Many others, however, are still searching and
would benefit immensely from serious theological reflection in this regard.
3. ECCLESIOLOGICAL ISSUES.
The final area of concern which I would like to pose here relates
to the nature and mission of the Church. I believe that the pandemic of
HIV/AIDS is forcing us to clarify once again the vision of our Church.
Throughout the world, I have observed the tendency to restrict membership in
the Church to those who might be considered sufficiently orthodox,
loyal, etc. Persons living with HIV/AIDS and their loved ones are
begging to be accepted and treated as full members of the Church in spite of
the fact that they may not always have been fully active or faithful to Church
teachings and practices. During a presentation which I gave several years ago
in a Latin American country, I reminded the audience which was filled with
priests, religious, seminarians and lay leaders that Jesus went in search of
the marginalized and the outcasts in his society -- even of the prostitutes. A
moral theology professor at the national seminary offered a response to my
talk. He pointed out that I was technically correct in recalling such actions
of Jesus. He quickly added, however, that seminarians in the country need not
search for such ministerial opportunities among prostitutes; this was work
better left to nuns and laypersons. Even more disturbing are the frequent
questions of gay men living with AIDS about why the church has no room for them
-- why the Church has to wait until they are dying to offer them gestures of
love and care. I have frequently been told by medical staff in some countries
of the South where polygamy might be practiced that priests often insist that
men who are at the point of death as a result of AIDS-related illnesses must
first abandon all their wives -- but one -- before they could receive any
sacraments or spiritual comfort. There does indeed seem to be an ongoing need
for theologians to pursue reflection on the truly Catholic
universal nature of the church.
Once again I must point out that many lay and religious workers
have organized some excellent outreach to marginalized persons living with
HIV/AIDS and have engaged them once again as full members of the Christian
community. They desperately need the support of others -- and especially of
theologians -- to affirm and support such work. A religious sister in Lebanon
recently recounted to me a special experience which points out the need for
such encouragement. She came to know a homeless man who was suffering with
AIDS; after much struggle, she finally was able to arrange for his
hospitalization so that some of his acute illnesses might be properly treated.
During the time of his hospitalization, he expressed a great interest to learn
more about the Church and to practice more deeply his newly revived faith. When
the man was ready to be released from the hospital, he once again had no one to
offer him appropriate shelter. The sister went to the local parish priest to
ask his assistance in offering the man temporary shelter. The priest was
certainly familiar with the man since the latter had lived outside the parish
church for the past several years. The priest was making Communion hosts when
the sister made her visit. She enthusiastically described the mans
physical and spiritual revival. Then she asked the priest to receive the man in
the parish house for a short time to assure that he could receive decent food,
be kept warm and be able to pursue some catechetical lessons. During the
sisters presentation, the priest continued to make his hosts without even
looking up at the sister; he offered no response whatsoever. Finally, the
sister pointed out: You, Father, are making hosts which will soon become
the Body of Christ; I am asking you also to receive into your house a man who
wants once again to be integrated into the Body of Christ. The priest
never did respond, so the sister took the man into her own home.
CONCLUSION
As I conclude this presentation, I am conscious that I have raised
many issues and concerns and have been able to offer few answers. I can only
assure you of my solidarity as we struggle together to reflect on the
theological implications of this new reality in our world. Several theologians
have raised questions with me about whether they could be helpful in the face
of such a disastrous pandemic. One theologian shared with me her doubts that
anyone really wanted to hear from theologians. Another described himself as a
member of an endangered species -- a moral theologian. I must tell
you of the deep need and strong enthusiasm for theological reflection which is
experienced by many persons living with HIV/AIDS and both those who offer
HIV-related education and service.
National Catholic Reporter, Posted March 9,
2001
|