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Counting the Cost

 from Papal Paralysis by R. John Kinkel, Lexington Books, 2014, Ch.11, pgs. 89-95

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The Vatican breakthrough amounted to rethinking the medical ethics principles that were well-known but had not yet been applied to this new disease (HIV/AIDS.) The secular world had its own reaction to Benedict’s statement: “Its about time’ snapped a physician who was being interviewed during a morning TV news program after the November surprise. The Catholic Church’s decision makers demonstrated that they move at a snail’s pace even when lives are at stake. As we come to the end of our journey about condoms, AIDS, and the Catholic Church, this simple question comes to mind: What if church officials would have acted sooner?

What if John Paul II had listened to Cardinal Lustiger in 1988? What if Benedict XVI had acted immediately upon the advice of Cardinal Martini in 2006? Obviously, things would have turned out differently for thousands of people … but how many?

The “What if?” is a well-known tool used by social historians to make a point. I do not consider this line of questioning an exercise for amateurs who cannot figure out what to do with their spare time. Many eminent historians have looked back at important events in our social world and speculated about what would have happened if just the opposite action occurred in history. Here are some examples:

  • What if John F. Kennedy was never assassinated?
  • Two-time Pulitzer Prize-winning historian Robert McCullough has pondered, “What if George Washington’s retreat after the battle of Long Island had not succeeded?”
  • [p.90] John Stacks and Lawrence Malkin ask, “What if Watergate were still just an upscale address?”
  • What if the Mayflower had never set sail?

Following this well-known literary device, I have decided to ask this question: What if the previous two popes (John Paul II and Benedict XVI) had never banned the use of condoms to prevent the spread of AIDS? What if pastors were told to encourage people from the pulpit and in the Sunday bulletin to be sure to use a condom if they were HIV positive because it was the right thing to do? How would this have changed the course of history and saved lives?

We know this could have happened because of the following three historical facts. First, it is obvious that many bishops and cardinals advocated the use of condoms to prevent the spread of AIDS, starting as early as the mid-1980s. They were leaders in the church and felt strongly that it was the moral thing to do, despite papal pronouncements to the contrary. Second, writers such as Marcella Alsan, MD, Peter Piot, and Nicholas Kristof have lamented that thousands—maybe millions—of lives have been lost because of the Catholic policy on condoms and AIDS. These are powerful assertions which irk many conservative Catholics who think the Vatican was right in banning condoms. Third, social and behavioral scientists such as Edward Green of Harvard and others have advocated a program of A + B + C for both poor and rich countries. That program of behavior change (abstinence and fidelity) together with condoms as a back-up plan provides one of the best chances to reduce the spread of AIDS. We have read the opinions of these experts for many years. So, we ask again: what if the Catholic Church early on would have approved a program to use condoms to fight the spread of AIDS? The three above groups would probably say “YES, they should have done this a long time ago.” Do we have any idea about the impact of such a hypothetical program if it had been implemented? Not precisely, but we can try to give a reasonable and thoughtful answer to the question.

The cumulative number of deaths worldwide as the result of AIDS was estimated to be 24 million in 2007 by John Bongaarts et al. of the Population Council. Scholars are aware that this number is probably an undercount, given the discoveries of Peter Piot and others. He has recently tested old blood vials from Africa (1976) and found HIV present in them. The Bongaarts group uses the best methodology to gather global AIDS statistics, and so we will utilize their database for this discussion despite its limitations. By 2009 the number of AIDS-related deaths stood at 27.8 million based on my own calculations using UNAIDS data for years 2008 and 2009 (figure 11.1).

These grim statistics tell us what has happened to the human race since 1981 when we began collecting reliable AIDS data. This disease is no ordinary pandemic; it is a “lethal illness with far-reaching implications for individuals, families, communities, health care providers and delivery systems… It has become the leading infectious cause of mortality

worldwide.”(1) For about three decades health care workers and scientists have been fighting this disease, and they have been able to limit its deadly effects to 27.8 million by the end of 2009. The total number of casualties could have been much worse without the heroic efforts on the part of many health care workers. We can only speculate about how much higher these numbers would have been without the concerted efforts of thousands of health care professionals and the generous grants from major research foundations throughout the world. About 14 percent of the deaths represented in figure 11.1 are children (ages zero to fourteen).(2) We now turn to the central question of this chapter, “What if?”—what if the Catholic Church had developed a viable program based on high quality medical and scientific research to deal with AIDS prevention during the period when many bishops were asking for change? Figure 11.2 below offers some reasonable estimates that we might have expected from a program initiated by Catholic Church officials in 2002, if they had listened to the many bishops and cardinals who had called for reform.

With three years of preparation, testing, and communication regarding the program, we have assembled some real and hypothetical data on preventable AIDS deaths that one could expect to find beginning in 2005. The columns in gray are actual worldwide deaths due to AIDS that come [p.92] primarily from the calculations of Bongaarts and associates.(3) This study takes a rather conservative view regarding program outcomes and posits that we could possibly observe a 2 percent reduction (black columns) in AIDS deaths each year (2005-2009) throughout the world due to the new Catholic program, namely, an agreement to encourage the use of condoms to prevent AIDS. This intervention model assumes that the Catholic Church aggressively promotes a program that allows its members to use condoms to prevent the spread of AIDS and save lives. The above hypothesis is not unreasonable given the fact that there are approximately 1.2 billion Catholics (16.9 percent of world’s population^ on the planet today, and the church has four-hundred-thousand priests on the payroll who could deliver the papal message. Using all aspects of media communication, the target population would be all Catholics in the world.

We have not even mentioned the involvement of lay ministers (male and female) who certainly would be a major part of the program. The idea that such a program would achieve the modest effect outlined in figure
is definitely within the realm of possibility. The Centers for Disease Control states, “Overall the preponderance of available epidemiologic studies have found that when used consistently and correctly, condoms are highly effective in preventing the sexual transmission of HIV infection and reduce the risk
of other STDs.”
(5) The goal is to reduce the number of HIV infections and deaths caused by AIDS and here are the figures we would expect in the five-year Catholic program. In 2005, instead of 2.2 million deaths, the 2 percent reduction due to the new program approved by Catholic leaders [p.93] would cut the number of AIDS casualties in that year by 44,000 (in black).

With 2.1 million deaths expected in 2006, we would reduce that number by 42,000 because of the 2 percent effect, and so on. In figure 11.2 one can see the projected reduction in years 2007,2008, and 2009. Of course other factors will be at work to lessen the number of deaths worldwide due to AIDS. Health care experts hope to have more antiretroviral drugs available in years to come which will further cut the number of deaths to some degree. Unfortunately only about half of those who need antiretroviral drugs today actually receive them.(6) The poorest countries have the least access to these life-saving treatments. With fewer people getting infected by the HIV virus (use of condoms becomes a priority for more people), the overall number of AIDS deaths would drop considerably.

Fewer people would need antiretroviral drugs (they have not become HIV infected) and that would save scarce health care dollars. In the five years we have selected for our study, we estimate that the total number of lives saved through the Catholic prevention model would have been 202,000 (44,000 + 42,000 + 40,000 + 40,000 + 36,000 = 202,000). Nicholas Kristof of the New York Times has said that the “Vatican’s ban on condoms has cost many hundreds of thousands of lives from AIDS.” We agree and feel his numbers are plausible. Marcella Alsan goes even further and says that the church’s opposition to the use of condoms may have meant the loss of millions of lives. The numbers these people in the field are proposing leave the ordinary reader breathless.

The proposed Catholic prevention model not only would reduce death rates, but it could change the trajectory of HTV infections for years to come. In figure 11.3 we present some real and hypothetical data on HIV infections had the Catholic model been implemented fully in 2005.

[p.94] In this discussion we project a modest 5-percent reduction in HIV infections as the result of the new Catholic initiative. In the year 2005 the total number of people living with HIV/AIDS was about 32 million, but if the Catholic program would have been implemented by then, we estimate that the number infected worldwide would have been reduced to 30.4 million—roughly a million and a half reduction. A modest 5-percent reduction could have meant a significant number of lives saved and a major reduction in the use of expensive antiretroviral drugs. In 2006 the new program would have resulted in about 1.6 million fewer HIV infections because condoms had become a significant part of the Catholic program to fight AIDS. Table 11.1 summarizes the overall program benefits over five years.

The cumulative effect of the Catholic program, if implemented, would have resulted in approximately eight million fewer HIV infections worldwide during the five-year period under consideration.

What this study has done for readers is provide a conservative estimate as to what the Catholic model could do for its members and many others who do not belong to the church, but who rely on Catholic-sponsored clinics for health care. It is well known that Catholic hospitals and clinics serve Catholics and non-Catholics alike, and so there is a chance for a greater impact with this program when we include the broad range of patients these health care facilities actually serve. The program would no doubt touch the lives of more than 1.2 billion Catholics.

Of course, some have said that AIDS is no longer a hot topic and is gradually fading into the woodwork as an important health issue. John Bongaarts and his colleagues(7) are not buying that argument at all. They point out that if all factors related to this disease remain constant, the cumulative death toll for AIDS in 2030 will be seventy-five million. Thus, it is not too late for implementing change, despite the church’s many failures to act upon the recommendations of bishops throughout the world.There are millions of lives to be saved if effective programs become a part of all social and religious service agencies.

[p.95] Many at the Vatican ought to apologize for past failings and admit their mistakes. Thomas Reese, SJ, thinks there are some bishops who should “lay down their crosiers” because they failed to properly manage the priest sexual-abuse problem in the Catholic Church.(8) lt would not be out of place for those church leaders who handled the AIDS crisis so poorly to do the same; many lives have been lost and this calls for serious church reform and accountability. No one I know, however, is counting on that to happen very soon. The words of Dr. Alsan bear repeating; the church’s opposition to the use of condoms “may mean not only untold human suffering, but the loss of millions of human lives.” It is time to turn the page on the past and promise Catholics that church officials have learned their lesson and there will be no repeat fiascos in the future.

1. William Cockerham, Medical Sociology, 12th ed. (New York: Prentice Hall, 2012), 37.
2. John Bongaarts, Francois Pelletier, and Patrick Gerland, “Global Trends in AIDS Mortality,” Working Paper #16, Population Council, New York, 2009:7.
3. John Bongaarts, Francois Pelletier, and Patrick Gerland, “How Many More AIDS Deaths?” Lancet 375 (2010): 103.
4. U.S. Census Bureau, Population Clock, estimates the world population to be 7,094,310,470, June 26,2013.
5. CDC,Condom Effectiveness (accessed April 14, 2013).
6. Erin Loury, “Scientists Make Curing HIV a Priority,” Los Angeles Times, July 23,2012.
7. John Bongaarts, “Global Trends,” 6-7.
8.Thomas Reese, “On Sex Abuse,” America, May 10,2012.