My previous post, giving credit where it is due to George Bush for his AIDS in Africa policy, did not deal with the important question of how to prevent the spread of AIDS in developing countries. On a trip to Africa this March, Pope Benedict XVI "angered health workers by restating the Vatican's opposition to the use of condoms to fight AIDS." That's from Reuters. You can find the clip here, at The Alligator. What did the Pontiff actually say? Here is my transcription:
I would add that the AIDS problem cannot be solved by money alone, even if necessary. It cannot be solved with the condom distribution. The condom distribution only makes matters worse. The solution can only be this: first, a humanization of sexuality and a spiritual renewal which implies new behaviors.
That's what I heard from the clip, which is a translation of the Pope's actual words, and is innocent of the context that might be provided by the entire exchange. I provide it, because I couldn't find even that much elsewhere. All the print accounts, and there are many, cut up the Pope's words.
Now I am not nor have I ever been a Catholic. I have no moral objections to the use of birth control devices that do not involve abortion. But is the Pope right that "condom distribution only makes matters worse"? That is an empirical question, and one would want evidence to evaluate it. Unless, of course, one knows what the right answer is and one wants to shut down any opposing opinions. Here is the Washington Post editorial on the Pope' comments:
While on a flight to Cameroon on Tuesday to begin a weeklong journey through Africa, Pope Benedict XVI said, "You can't resolve [the AIDS epidemic] with the distribution of condoms. On the contrary, it increases the problem." In a perfect world, people would abstain from having sex until they were married or would be monogamous in committed relationships. But the world isn't perfect -- and neither is Pope Benedict's pronouncement on the effectiveness of condoms in the battle against HIV/AIDS. The evidence says so.
Well, does the evidence indicate that condoms are effective in the fight against AIDS? The WaPo provides no evidence at all. That's because the evidence, such as it is, is on the Pope's side. Edward C. Green is the head of the Harvard based AIDS Research Center. He is also a Senior Research Scientist at The Harvard School of Public Health. He has weighed in on this question at the Washington Post:
In 2003, Norman Hearst and Sanny Chen of the University of California conducted a condom effectiveness study for the United Nations' AIDS program and found no evidence of condoms working as a primary HIV-prevention measure in Africa. UNAIDS quietly disowned the study. (The authors eventually managed to publish their findings in the quarterly Studies in Family Planning.)
Since then, major articles in other peer-reviewed journals such as the Lancet, Science and BMJ have confirmed that condoms have not worked as a primary intervention in the population-wide epidemics of Africa.
In a 2008 article in Science called "Reassessing HIV Prevention" 10 AIDS experts concluded that "consistent condom use has not reached a sufficiently high level, even after many years of widespread and often aggressive promotion, to produce a measurable slowing of new infections in the generalized epidemics of Sub-Saharan Africa."
And this, also by Professor Green, from the London Times:
In an interview with the National Review Online, Mr Green said: “We have found no consistent associations between condom use and lower HIV-infection rates, which, 25 years into the pandemic, we should be seeing if this intervention was working.”
Well, yeah. After 25 years of trying something, it doesn't work probably means it doesn't work. But common sense surely supports condom distribution. Condoms may fail, and they are not always used consistently, but if they are used at all that ought to add up to something. Why doesn't it? Green offers some possible explanations:
One reason is "risk compensation." That is, when people think they're made safe by using condoms at least some of the time, they actually engage in riskier sex.
Another factor is that people seldom use condoms in steady relationships because doing so would imply a lack of trust. (And if condom use rates go up, it's possible we are seeing an increase of casual or commercial sex.) However, it's those ongoing relationships that drive Africa's worst epidemics. In these, most HIV infections are found in general populations, not in high-risk groups such as sex workers, gay men or persons who inject drugs. And in significant proportions of African populations, people have two or more regular sex partners who overlap in time. In Botswana, which has one of the world's highest HIV rates, 43 percent of men and 17 percent of women surveyed had two or more regular sex partners in the previous year.
These ongoing multiple concurrent sex partnerships resemble a giant, invisible web of relationships through which HIV/AIDS spreads. A study in Malawi showed that even though the average number of sexual partners was only slightly over two, fully two-thirds of this population was interconnected through such networks of overlapping, ongoing relationships.
Now that "giant, invisible web of relationships," looks to me like the fundamental cause of the epidemic in Africa. If enough sexual partnerships involve third persons, one has an efficient vector for the transmission of a sexually transmitted virus. Hence, Green asks:
So what has worked in Africa? Strategies that break up these multiple and concurrent sexual networks -- or, in plain language, faithful mutual monogamy or at least reduction in numbers of partners, especially concurrent ones. "Closed" or faithful polygamy can work as well.
In Uganda's early, largely home-grown AIDS program, which began in 1986, the focus was on "Sticking to One Partner" or "Zero Grazing" (which meant remaining faithful within a polygamous marriage) and "Loving Faithfully." These simple messages worked. More recently, the two countries with the highest HIV infection rates, Swaziland and Botswana, have both launched campaigns that discourage people from having multiple and concurrent sexual partners.
Now I am no expert in epidemiology, but I understand this much: the way to control an epidemic is to shut down the vectors of transmission. It looks like condom distribution is not effective. Policies encouraging marriage (even polygamous marriage) are effective. Maybe we should concentrate our efforts on what works. I don't know if the Pope is infallible, but maybe he isn't always wrong. He might even be smarter than the Washington Post.
I do have a problem with the Popes statement, assuming he was translated and quoted accurately. Condoms are not necessarily making the problem worse and saying so is counter-intuitive. But, considering the Catholic church's stance against all birth control, his statement is hardly unexpected.
Drawing conclusions from statistics is always iffy business. This may be the case re. condom use/distribution in the fight against the spread of aids in Africa.
We do know that condoms, when used properly, will stop the transfer of the aids virus during intercourse. So how then to explain no reduction or even increases in the incidence of aids cases when condoms were distributed widely and the use was advocated for years? Perhaps it's a bit like pouring water on a fire that has a never-ending source of fuel. The fire continues to burn and may increase depending on the balance of water to fuel. But, absent the water, the fire would grow even greater. Which is to say condoms are not necessarily a failure in fighting aids or a cause of its spread, they just aren't the whole answer.
The fuels firing Africa's aids pandemic are many and no doubt vary by country. To name a few: South Africa basically denied the existence of the aids problem for decades. In many countries, there is widespread ignorance of aids prevention born out of illiteracy in turn born out of poverty. There are male dominated cultures that deny property rights to women meaning widows and other single women are often forced into prostitution to support themselves and their children.
That committed relationships do curtail the spread of aids is certainly true. But it will require much more than the Pope calling for: "...a humanization of sexuality and a spiritual renewal which implies new behaviors" and it will require more than condom distribution. It will take better education, reduction in poverty, cultural changes and more--the fundamentals that allow for, in a practical sense, humanized sexuality and spiritual renewal.
Posted by: A.I. | Monday, April 13, 2009 at 10:49 AM
A.I.:
Thanks for the comment. You say: "Condoms are not necessarily making the problem worse and saying so is counter-intuitive." Indeed. It is an empirical and not a logical question. But a lot of things that are counter-intuitive turn out to be true. Heavy things don't fall faster that lighter things. Dispensing more antibiotics can actually promote the spread of infectious diseases. Food aid to Africa has made matters worse there.
You compare the distribution of condoms to pouring water on a raging fire. The fire would be even higher without the water. Maybe. But if you are actually pouring kerosene on the fire, someone might make the same argument. You still have to determine if you are suppressing the fire or feeding it.
The problem with condoms is that they only work as instruments of responsible behavior. Handing out the little packages without encouraging the latter may indeed make matters worse. The most successful policies in Africa have been those that encouraged what the Pope would regard as moral behavior. Yes, he has a doctrinal bias against condoms, just as liberals have a doctrinal bias in favor of condoms and against abstinence and fidelity as objects of social policy. I don't care about condoms one way or the other. I just want to know what works.
Posted by: KB | Tuesday, April 14, 2009 at 08:10 AM
I won't pretend to speak for all liberals--if that term describes me--but I have no "doctrinal bias in favor of condoms and against abstinence and fidelity as objects of social policy". I do have a bias against a one-size-fits-all (no reference to condoms intended) approach to solving social problems. And it seems to me that is what the Pope is advocating.
As I noted in my first post, I do not consider condoms the total solution. The Pope and the studies you cite are likely correct that they are not the single most effective solution and promotion of abstinence/fidelity very well may be. But that does not mean a significant minority is not better served by condom distribution coupled with aids awareness education.
Posted by: A.I. | Tuesday, April 14, 2009 at 05:01 PM
A.I.:
I intended no accusation against you with the comparison of the Pope and liberals, just a point about the political context. The Washington Post editorial, and many of the reactions to the Pope's statement and to Edward Green's argument indicate that the Left just doesn't want to hear contrary evidence about condom distribution policies. The fate of the U.N. study sponsored and then withdrawn is further evidence of that.
In his WaPo piece, Green indicates that condoms sometimes do work. That looks to me like someone who cares about the evidence.
Posted by: KB | Tuesday, April 14, 2009 at 09:28 PM
"We do know that condoms, when used properly, will stop the transfer of the aids virus during intercourse".
Can youreference that for me?
The AIDS/HIV virus is very small and the pores of latex are very large in comparison. All of the physicians that I know always double glove if there is even a hint of a possibility of HIV infection. Some of them double glove all the time. I always double glove if blood or body fluids are likely to touch my gloves.
How many men (in Africa) use double condoms?
I am not Catholic but on this one the Pope has science on his side.
Please reference for me a scientific study that proves that condoms--when used properly--stops the transfer of HIV.
Posted by: Registered GYN Nurse | Saturday, April 18, 2009 at 11:30 PM