Crusading for change

Sophie Arie, Rome

For Luyanda Ngonyama, like the rest of his generation of South Africans, AIDS is part of everyday life. But condoms are not. One in five South Africans is living with HIV or AIDS, more people than in any other country.

For years, working for the South African Catholic Bishops Council AIDS programme, Mr Ngonyama, aged 32, saw fellow Catholics grapple with the moral dilemma over whether to use all available methods of protection. "What about my religion?" they would ask. "If I have sex [outside marriage] and use a condom, I'll be committing a double sin."

Mr Ngonyama became so uncomfortable with the Catholic church's official line on condoms—that they "promote immoral behaviour" and don't help protect from AIDS—that he gave up his job as HIV coordinator in the council programme. He now works for Treatment Action Campaign, the country's most influential AIDS activist group and a prominent pro-condom voice.

"I don't ever push Catholics to use condoms. But they must be free to choose. Any intervention on AIDS that doesn't include condoms is meaningless," Mr Ngonyama says. Mr Ngonyama is just one of countless Catholics around the world who have concluded that, where condoms are concerned, Pope John Paul II was out of touch.

When Karol Wojtyla became pope in 1978, AIDS had not yet raised its ugly head. In the time that he occupied the Holy See, the disease became a global epidemic, eventually killing more than 3.5 million people a year. But the pope continued to ban all forms of contraception right up until his death. The Catholic church's footsoldiers around the world spread the myth that condoms do not prevent the spread of disease because they are full of little holes. The message confused and intimidated many believers, gave reluctant condom users a perfect excuse, and inspired ultra-Catholic governments to ban or withdraw funds for distribution of condoms or information about them.

MASSIMO SAMBUCETTIS/AP
Pope Benedict XVI it is then

In the Philippines, where almost 85% of the population are Catholic, Juan Flavier, a health minister who launched a campaign promoting condoms in the 1990s, was denounced as an "agent of satan" by former Archbishop of Manila Cardinal Jaime Sin. Cardinal Sin issued a pastoral exhortation in 2001 stating that "the condom corrupts and weakens people… destroys families and individuals… and spreads promiscuity."

Today, the government of President Gloria Macapagal-Arroyo does not allow the use of government funds to supply condoms, and local authorities and prominent politicians, such as the mayor of Manila, have banned state health centres from handing them out.

In Chile, leading Catholic television channels have refused to air AIDS programmes that advise the use of condoms. In Kenya, Archbishop Ndingi Mwana a'Nzeki told his flock that condoms actually give people AIDS, and, in Zambia, the government of President Levy Mwanawasa has banned the distribution of condoms in schools. South Africa's Cardinal Wilfrid Napier attacked the government earlier this year for its latest condom awareness campaign.

Health and non-governmental organisations, Catholic or not, find that the Vatican's anticondom message has created a kind of cultural minefield that they must tiptoe around. Although many Catholics choose to ignore the message, in developing countries, such as in Africa, where Catholicism is recruiting new and fervent believers faster than anywhere else in the world, the church appears to be working directly against public health workers.

Smaller aid agencies and human rights campaigners describe being intimidated by government or church officials in countries such as Kenya, Nicaragua, Zimbabwe, and Nigeria. And many people, whose funding does not depend on good relations with the United States or with the church, are open in their belief that John Paul II's stance on condoms has contributed to the deaths of many thousands of people.

"If people are not keen on using condoms and you give them another excuse, that may cost them their life," says Annabel Kanabus, director of UK based AIDS charity AVERT. "If the Church does not change its line, more people will die."

"It is most unfortunate that the Catholic church has taken the wrong stance on condoms. It is a major blotch on its otherwise very good work," says Nathan Geffen, national manager of the Treatment Action Campaign in South Africa, where 400 000 new infections were reported last year.

Some of the greatest criticism in recent years has come from Catholic aid agencies and Catholic priests working in AIDS ravaged areas, many of whom have openly distributed condoms and demanded that the church revise its position.

"What's really ironic is that Catholic organisations provide about 25% of care for all HIV/AIDS victims," said one member of an international Catholic aid group. "And yet it is controversial for us to hand out condoms to try to slow the spread of the disease."

According to US based Catholics for a Free Choice, most Catholics, even in the church's most traditional heartland of Latin America, think that it is time condoms were given the green light. In Mexico, 91% are in favour; in Bolivia 79%.

Frances Kissling, president of Catholics for a Free Choice, believes a pope is going to have to give in. "John Paul II was a great believer in the slippery slope argument. He took the authoritarian father attitude," says Ms Kissling. "But he was not at the top of his game in the last five years. Had the question been explored at a time when he was more functional, I'm sure he would have been able to see the point. One of the first things the new pope should do is save lives. It's doable. It's going to happen."

Many health organisations fear that if the church's stance does not change under the new pope, Benedict XVI, the effect, combined with America's support for abstinence campaigns, will be that funds will dry up for condom distribution and promotion around the world.

"If we have a new pope who goes along the lines of John Paul II, and we combine that with the abstinence message coming from the US, we will have a tragedy that could put hundreds of thousands of people at risk," said Ms Kanabus.

Already, only a fifth of the $15bn (£8bn; €12bn) allocated to fighting AIDS in the next five years is to be spent on AIDS prevention. And of that, 30% is earmarked for abstinence campaigns. Much of the US funds is channelled through faith based organisations.

Technically, it would not take much for Benedict XVI to change the party line. The Vatican's encyclical Humanae Vitae, issued by Paul VI in 1968 bans all forms of contraception. But AIDS was not an issue at the time and the encyclical does not rule either way on how to avoid sexually transmitted diseases. This means changing the Vatican's stance is not a question of formally revising written doctrine.

It would be very easy for the new pope to change the official line," said Mr Kissling, who plans to raise the issue in a letter to Benedict XVI. "All he'd have to do is say it." Unfortunately the new pope was for the past 24 years defender and promoter of the Vatican's increasingly unbending orthodoxy.



studentBMJ 2005;13:177-220 May ISSN 0966-6494