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.
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