God, AIDS, Africa & HOPE

Stefan Hippler

Health warrior from Europe – Antiretrovirals are indispensable – but not a cure

The little guy was just skin and bones when he was brought into the care of HOPE Cape Town. He was just two years old and HIV-positive. His parents had little hope that he’d ever be healthy again. A few months later they were amazed by the effects of antiretroviral therapy. Their mortally ill son had turned into a lively infant who crawled around excitedly, just like any toddler in the world. The parents regained their determination and hope.

On his third birthday we – parents, relatives and I – stood at the boy’s grave. What had happened?

Initially the strong medication had a therapeutic effect on the boy’s system. But then came the night when he suddenly collapsed. The parents had no money to pay for transport, so they carried him on foot. Hours later they arrived at Tygerberg Hospital. Too late. Shortly after they arrived, the child died – and nobody really knows why. The doctors suspect acidosis (too much acid triggering an imbalance in the blood) caused by the drug AZT. That can happen with children, and the reaction requires timely intervention. But the cause of death was to remain the doctors’ best guess; an autopsy would have been much too expensive.

The story of the boy illuminates a neglected feature of the HIV/Aids problem. All the drugs that extend and improve the lives of HIV-positive patients were developed specifically for adults. So far medical scientists have not succeeded in establishing the specific side effects of these medications on infants and toddlers on a long term. Millions of Rands are being spent on research in South Africa to study this phenomenon. The money comes mainly from the United States, and if one wished to be spiteful, one might say that South Africa is like a big research laboratory, with minors as guinea pigs, to determine the effects of medicines on children.

This may be exaggerating matters, but research practices do raise serious ethical questions. At what age should children receive treatment? Is it prudent to expose babies to these heavy-duty drugs? What are the effects of therapy in cases where childcare is inadequate, as often happens in townships for many reasons? There is not a single Church document that deals with such ethical issues. Talk about the great benefits of ARVs is not helpful when there is no effective structure to control their regimen (without which ARV therapy is certain to fail).

And yet most experts invest an unwavering faith in a pharmaceutical solution, always obsessions of modern medicine. They declare war on the virus and send their Aids warriors into battle against the virus. But their weapons – cocktails and condoms –often misfire. Many people see no point or reason in preventative measures. They don’t relate to the Western understanding of hygiene. They take the pills with contaminated water. Then they vomit out the drugs because their undernourished bodies cannot handle them. They take their medications randomly or incorrectly because they live in chaotic conditions. There usually is nobody who can supervise and control the essential discipline. Some patients even sell their medications to make ends meet.

At best, the health warriors can reduce the effects of the pandemic. But they cannot fix the causes of the pandemic – mass poverty, ignorance, and sexual domination. Perhaps one needs to be in Africa to fully understand that here Aids is not a medical but an economic, social and cultural problem. But what alternatives can the health warriors turn to? So they continue to place unconditionally trust in ARVs, as if medical therapy is going to be a miracle cure.

HOPE Cape Town was one of the first organisations in the Western Cape to distribute ARVs – and among the first to warn against their inappropriate use. We did so because the haphazard consumption of Aids drugs can create dangerous viral resistances. When our patients go home to their villages in the Transkei, we are left with piles of medications. But they must take the drugs every day at the same time, for the rest of their lives; if they don’t, drug resistance will end  the therapy.

Even people in the Treatment Action Campaign (TAC), South Africa’s most influential Aids activist organisation, see ARVs as the most effective multi-purpose weapon – as if the disease would be defeated if only all patients were taking them. But not all people who are HIV-positive require ARV treatment. And therapy can succeed only if it is carried out with rigorous discipline. Many areas of South Africa lack the conditions for the rigorous regimen demanded by the therapy. There is a lack of clinics, equipment and qualified personnel. So one should be dubious about populist slogans like “Treatment for All”, which raise the hopes of people without the possibility of these ever being met.

Meanwhile studies show that mortality among ARV patients from disordered environments is higher than among those fortunate to have been born into stable circumstances. This shows that medication alone is not a solution: poverty, deficient infrastructure and social conditions are crucial factors in the success or failure of medical treatment.

In light of all this, we have to deal with the epidemic holistically, with an integrated approach. In this field the Church in particular faces a challenge. The HIV/Aids problem calls on the Church to promote its charism of justice and peace in safeguarding God’s creation. The Church should provide leadership in response to this human catastrophe. We, the Catholic Church with its 1,2 billion followers, are a global player with enormous influence. We have a moral obligation to change the face of the earth and to tackle the issue of HIV/Aids constructively. And this global engagement begins with the youngest victims, such as that helpless little fellow whose distressing story I told at the beginning of this chapter.

Translation from:
Gott – Aids – Afrika
Hardcover: 207 pages  –  Publisher: Kiepenheuer & Witsch GmbH (August 31, 2007)
Language: German  –  ISBN-10: 3462039253  –  ISBN-13: 978-3462039252
Gott – Aids – Afrika
Paperback  – Bastei – Luebbe  –
Language: German  –  ISBN-10: 3404606159  –  ISBN-13: 978-3404606153

Filed under: General, HIV and AIDS, HIV Prevention, HIV Treatment, HOPE Cape Town Association & Trust, HOPE Cape Town Trust, Medical and Research, Networking, Politics and Society, Reflection, Society and living environment, Aids, bartholomaeus grill, book, cape town, Catholic, catholic church, Church Matters, gott-aids-afrika, hiv, HOPE Cape Town Association & Trust, HOPE Cape Town Trust, moral theology, oekonomia, people living with the virus, pope, sexuality, south africa, stefan hippler, theology, Theology

Stefan Hippler

Unstained by real life  –  Why good intentions often fail in the face of African realities

We are celebrating Mass at Kolbe House, the University of Cape Town’s Catholic chaplaincy. This Sunday we Catholics recall Mary’s Immaculate Conception. It is a real challenge to explain this theme to students. A stainless conception – how is that supposed to work? What is that priest talking about? Related questions come up during a small workshop after the Mass. Of all days, it is on the feast day of the Virgin Mary that we are scheduled to discuss HIV/Aids and sexuality. I notice a poster on the wall. The poster, which bears the logo of the Southern African Catholic Bishops’ Conference (SACBC), was developed in cooperation with the Association of Catholic Tertiary Students. Beneath the image of a black cross with a red Aids ribbon is the slogan, “ABCD Lifestyle campaign: Catholic youth responds to Christ’s call”.

The acronym is an allusion to the ABC strategy which is being used around the world to promote HIV/Aids prevention, but which is also controversial because it neglects women and girls. As explained earlier, it stands for “abstain”, “be faithful”, and “condomise”. The students’ association’s approach to the first two points is identical, but it takes the opposite direction on the third recommendation and adds a fourth one. On the poster, C stands for “Change your lifestyle”, and D issues a warning: “Danger of not living your life to the fullest”.

So the students are called to chastity, asked to resist not just the enticements of Eros but also a series of other temptations. The content of that series of temptations takes me by surprise: crime, corruption, drug use, pollution and vandalism. I’m puzzled as to how sexuality and criminality can be linked in one breath. Even the reference to fidelity leaves a strange taste in the mouth. The young person is being challenged to be faithful to their bodies, families, friends and parish, but concepts such as girlfriends or boyfriends, life partners, wife or husband are not mentioned. And then C and D: change your lifestyle or you’ll risk not being able to live your life “to the fullest”, in line with the Gospel of St John (10:10). Because one might be a criminal. Or a drug addict. Or a litter bug. Or because you could be infected with HIV.

That is quite something from a Catholic organisation. How exactly do we know that a person with HIV cannot live her life “to the fullest”? Isn’t that a rather audacious presumption which contradicts our faith that for God nothing is impossible?

So we go through the poster, point by point, and I ask the students for their comments. Most of them contemplate the content of the poster for the very first time. They respond, hesitantly and cautiously – they are not used to discussing such things with a priest. He might be very nice, but he is still a representative of the institutional Church. Gradually the unease lifts, and it turns out that nobody here likes the link between sexuality and crime. And they are all reflecting on why a person with HIV should not be able to live a full life. Because they die so quickly, says a student. And because they can’t have children, adds another. Conclusion: the Church tries to give guidance but causes confusion.

I take this bizarre poster to the next meeting of the archdiocese of Cape Town’s Catholic Aids Network, and vent my anger. That sparks an exciting debate. What should all the children born with HIV think of being placed on the same level as criminal offenders? What are they supposed to think of being prophesied an unsatisfying life because they cannot live it “to the fullest”? Our meeting spontaneously resolves to write two letters. The first will be addressed to Cardinal Wilfrid Napier, at the time the bishop conference’s president. We want to know from him whether the content of the ABCD poster was ever collegial passed in line with the conference’s principle of consensus – after all, it bears the SACBC logo. The second letter will be sent to the priest who is responsible for the students’ association’s poster, asking him to clarify the meaning and purpose of this campaign.

It takes weeks before we receive a reply. The first comes from the cardinal. He explains that he is not responsible for the poster and never actually saw it in detail. Just how the SACBC logo found its way on to the poster will remain a mystery. Cardinal Napier suggests that we ask the originators directly. But that turns out to be not that simple. The priest at first doesn’t respond. When, after further approaches, he does, his answers are as vague as we had feared. Nobody is really accountable for it, we learn. And what these posters communicate to people with HIV, well, nobody really thought about it. Should I be angry? Or should I console myself with the idea that sometimes such things are just “typically Catholic”?

But considering that most Aids education campaigns fail or are misdirected, just how are we going to reach the youth? What can we do to stifle the rate of new infections? What kind of strategy is the Catholic Church in South Africa developing for the next five years? First we cared for Aids orphans. Then we opened clinics and hospices. Now we are concentrating on the distribution of medicines. But what are we going to do next? We haven’t arrived at a satisfactory answer yet.

But let’s look at that poster again. It recommends that black students should develop their conscience and live their culture. But we haven’t even started to understand African culture, and often know nothing about it. I’ll try to demonstrate this with three examples.

Among traditional Xhosas, one of the dominant nations in South Africa, it is quite common that a man will take four wives. So if he “lives his culture”, he breaches the Christian requirement for monogamy. But his aim is to produce many descendants, because not only does that ensure the survival of his clan, but also that he will be cared for in old age. I began to understand that principle through the experiences of an employee of HOPE Cape Town. She was about to become the second wife of a man, and was already pregnant with his child. But her future husband died shortly before the wedding. When I asked how her family was coping with these circumstances, her answer astonished me. The most important thing, she said, is that he now has a descendant. Her parents had already been concerned that at her advanced age she had still been without child.

The second example concerns sexuality. Those who live their African culture categorically don’t speak about it, and even less so about Aids. Even Nelson Mandela, the brave freedom fighter and South Africa’s first black president, would refer to it only marginally. Once, after his retirement, he pointed out that for men of his standing, brought up according to traditional values, speaking about sexuality isn’t easy. For a true African it is non-negotiable that body fluids will have to be emitted during sexual intercourse, and the use of a condom would preclude that. And many African cultures maintain the custom of dry sex. Men don’t want the woman’s vagina to be moist during intercourse because that supposedly enhances the experience. But it also significantly increases the risk of HIV infection.

The third example concerns illness and healing. A complex universe of gods, ghosts and ancestors still form the mind of many Africans. The ancestors exercise a strong influence on daily life – they protect or curse and reward or punish their descendants. And because every illness is a sign or call from an ancestor, the living individual is not responsible for it. The healing is the sangoma’s job. The traditional healer has the secret wisdom and knows the rituals to beat the sickness. His patients will consider themselves healed as soon as the symptoms of the ailment disappear. In terms of the asymptomatic phase of HIV, during which the immediate effects of the infection soon disappear, this philosophy can have fatal consequences.

One could raise more examples. I mentioned just three to demonstrate that the advice to live one’s African culture is just thoughtless. And that’s how many suggestions on the ABCD poster seem: thoughtless. Unstained by reality. But reality demands that we face different challenges if we want to fight the virus effectively. The African relationship to sexuality, to gender roles, to death, to traditions must be modified; African men must change. Africa needs a mental revolution.  And the church must learn, that universal and unique moral teaching might mean trouble for specific regions.

The Poster: ABCD

Translation from:
Gott – Aids – Afrika
Hardcover: 207 pages  –  Publisher: Kiepenheuer & Witsch GmbH (August 31, 2007)
Language: German  –  ISBN-10: 3462039253  –  ISBN-13: 978-3462039252
Gott – Aids – Afrika
Paperback  – Bastei – Luebbe  –
Language: German  –  ISBN-10: 3404606159  –  ISBN-13: 978-3404606153

Filed under: General, HIV and AIDS, HIV Prevention, HIV Treatment, HOPE Cape Town Association & Trust, HOPE Cape Town Trust, Medical and Research, Networking, Politics and Society, Reflection, Society and living environment, Aids, bartholomaeus grill, book, cape town, Catholic, catholic church, Church Matters, gott-aids-afrika, hiv, HOPE Cape Town Association & Trust, HOPE Cape Town Trust, moral theology, oekonomia, people living with the virus, pope, sexuality, south africa, stefan hippler, theology, Theology

Stefan Hippler

Right to life or death penalty?  – The contradictions in Catholic moral teachings

How does your church react to the pandemic? What guidance does it give? What measures does it recommend? What is it doing? These are the kind of question Catholic priests are likely to face in the era of HIV/Aids. In theological terms, the Church has no official, defined teaching on the question of HIV/Aids: there are still no answers to the fundamental challenge we are facing. So far a few cautious inferences have been voiced with reference to Church teachings, manifesting the immense gulf between theory and practice. They do not equip the pastor with spiritual tools but more likely drive him to struggles of conscience.

When it comes to care for Aids patients and those affected by it, the Roman Catholic Church is at the forefront. Many consecrated women and men literally sacrifice themselves in the service of suffering people. In many developing countries it is in particular Catholic establishments that carry the greatest load in supporting the Aids-affected because state institutions often are overextended. Many Church leaders around the world have emphasised this service to humanity. My home diocese of Trier pointed out as early as the 1980s that it is an ancient obligation that the Church must stand in solidarity with the suffering and the dying. The diocese stressed that any form of discrimination or stigmatization of HIV-positive people is unchristian. Some theologians even refer to the Body of Christ as having Aids, thereby creating a way to view the disease theologically.

These brave notions stand in contrast to the rigidity and ignorance of many bishops and priests who are still not prepared to tackle the issue of HIV/Aids. Some of them even deny that the disease is a problem in their dioceses. Their resistance ranges from the pious observation that Aids is a punishment from God to a priest asking an HIV-positive parishioner to leave his congregation. Those in charge of the Church are intimidated by HIV, Aids and the implicit association with sexuality. They don’t want to confront these issues because to do so they must enter the minefield of moral theology.
The Church teaches that sexuality belongs in marriage, and only in marriage. It may be practised only in a life-long partnership between a man and a woman who remain faithful to each other. Everything else – premarital sex, homosexuality, multiple partners, one-night stands, cohabitation, polygamy – is sinful. Within the institution of marriage, sexuality was reduced to the dictum of the Church Father St Augustine who taught that every sex act must be open to procreation. Artificial contraception is regarded illicit with reference to the encyclical Humanae vitae, issued by Pope Paul VI in 1968. In an official handbook for confessors, approved in 1997 by Pope John Paul II, the late Cardinal Alfonso López Trujillo, then prefect of the Pontifical Council for the Family, emphasised the unequivocal teaching authenticity of Humanae vitae: “The Church has always taught the intrinsic evil of contraception, that is, of every marital act intentionally rendered unfruitful. This teaching is to be held as definitive and irreformable.” And God wills this regulation, according to the pope as the supreme guardian and teacher of the magisterium. The will of the Almighty permits no discussion, and accordingly there are no ways of dispensing believers from it. Thus millions of people become sinners because they live in defiance of God’s will as defined by the Vatican. And so they must bear the consequences of their godless behaviour, at least as far as fundamentalist theologians are concerned.

Among the proscribed artificial instruments of contraception are condoms. These are, as we know, the only effective means of preventing the exchange of bodily fluids during sexual acts. The Church’s teaching on condoms, still controversial and puzzling to many, refers solely to procreation, but extends now to questions of life and death. The moral theologian Carlo Caffarra – now archbishop of Bologna – in 1989 even called for an end to sexual activity within marriages in which one partner is HIV-positive. Our Church held on to that approach for years. Only a few bishops dared to invoke the difference between protection and procreation of life.

The Belgian Cardinal Godfried Danneels pleaded for the use of prophylactics when one spouse is infected. “Otherwise one sin – breaking the sixth commandment (Thou shalt not commit adultery) – is compounded by another sin, breaking the fifth commandment (Thou shalt not kill).” The German theologian Professor Johannes Reiter called for condoms to be tolerated in some cases as“disaster prevention”. But such ideas have failed to penetrate the centre of the Vatican. Perhaps the Vatican’s new doctrinal study into the use of condoms in the fight against Aids commissioned by Cardinal Javier Lozano Barragán will usher in a change; it reportedly has been circulated already to Pope Benedict XVI and the doctrinal congregation. Cardinal Barragán was the Vatican’s de facto health minister, and he has exercised his mind for some time on the question of whether marital condom use can be licit on the grounds of self-defence when one partner is infected.
As things stand, there is no deviation from the official teachings of the Church. Indeed, the 1968 Königsberg Declaration in which the German bishops emphasised spouses’ freedom of conscience is at risk of being withdrawn so as not to impugn on papal primacy. It seems that papal infallibility is being virtually expanded to include pronouncements which have not been issued ex cathedra, i.e. the official decisions declared by the pontiff in college with the Church under the guidance of the Holy Spirit which are to be regarded as infallible. So people with HIV, who already have sinned, must now also accept that the only available method of protection for their partners is proscribed. Those who use condoms commit one sin on top of another. Of course there is an alternative: abstinence.

But doesn’t our Church teach that celibacy is a gift from God and not intended for every one?

There is a big contradiction in the teachings of our Church: in its support for and care of those with Aids, the Church is a leading light, but at the same time it also contributes to the discrimination of these people. It seems perfectly schizophrenic to call people to a full life with intimacy in holy matrimony, and then deny infected people that intimacy. Catholic moral teaching places the right to life at its centre. But then it puts people who follow that teaching at risk of infection by a deadly virus. The ultimate tragedy resides in our Church’s refusal to reconcile the principles of its moral theology with the insights from sociology, psychology, sexual research and other social sciences. I would add my perception that the Church lacks in humility – the humility to realise that all human knowledge is like patchwork, that nobody has a monopoly on all truth. That’s why the Church does not perceive HIV/Aids as a Sign of the Times, one that not only questions the conduct of individuals, but also that of the Church in its totality. In theological terms, I see the suffering and dying of Aids-infected brothers and sisters as a cry from God. The Church, the Body of Christ, is infected with the virus, and in that body there are only those who suffer and those who suffer with them.
But, one might demur, is it really that important what the Church thinks and does in these permissive times? Does it still have a substantial role to play in global terms? There are so many other churches, congregations and faith movements, and many people have abandoned religious traditions altogether and believe in nothing. That objection is easily rebutted: the Catholic Church has 1,2 billion members. It is the biggest cohesive religious community in the world. As the world’s largest institution it could fight against HIV/Aids like no other. It really could – if only it wanted to.

Translation from:
Gott – Aids – Afrika
Hardcover: 207 pages  –  Publisher: Kiepenheuer & Witsch GmbH (August 31, 2007)
Language: German  –  ISBN-10: 3462039253  –  ISBN-13: 978-3462039252
Gott – Aids – Afrika
Paperback  – Bastei – Luebbe  –
Language: German  –  ISBN-10: 3404606159  –  ISBN-13: 978-3404606153

Filed under: General, HIV and AIDS, HIV Prevention, HIV Treatment, HOPE Cape Town Association & Trust, HOPE Cape Town Trust, Medical and Research, Networking, Politics and Society, Reflection, Society and living environment, Aids, bartholomaeus grill, book, cape town, Catholic, catholic church, Church Matters, gott-aids-afrika, hiv, HOPE Cape Town Association & Trust, HOPE Cape Town Trust, moral theology, oekonomia, people living with the virus, pope, sexuality, south africa, stefan hippler, theology, Theology