Observations Yankee Doodling

The papal position on condoms and HIV

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1217 (Published 25 March 2009) Cite this as: BMJ 2009;338:b1217
  1. Douglas Kamerow, chief scientist, RTI International, and associate editor, BMJ
  1. dkamerow{at}rti.org

    It would be a blessing if Benedict XVI could stop advocating policies that endanger the health of some of the world’s neediest people

    When I was aged 6 or so I used to go through my father’s top dresser drawer looking for pennies. One day I found a strange rubber balloon wrapped in foil. I didn’t know what it was and didn’t recognise the big word printed on the outside of the wrapper: “prophylactic” (this was the genteel 1950s). An inquisitive child, I looked it up in the dictionary and found out that the word meant “acting to defend or prevent something, especially a disease.” I idly wondered what disease my father was trying to prevent with this balloon but soon lost interest.

    I thought of this memory when I read about Pope Benedict XVI’s recent comments about the use of condoms to prevent HIV transmission (BMJ 2009;338:b1206, doi:10.1136/bmj.b1206). As I write this, news accounts of his recent trip to Africa have been dominated by reactions to comments he made as he was flying there from Rome. He was quoted as saying that AIDS “can’t be resolved with the distribution of condoms.” “On the contrary,” he said, “it increases the problem.” Health officials and editorialists around the world have strongly objected to the pope’s statement, but I think that there is more to the story than just correcting his facts.

    It is no surprise, of course, that the pope is against the use of condoms and supports sexual abstinence as the best way to prevent the spread of HIV. He rejects condom use as part of the Catholic church’s position against what it terms “artificial contraception.” As many have already pointed out, however, the pope was just plain wrong when he said that condoms make the AIDS problem worse.

    Many studies done around the world, including in Africa, have found that condom use can decrease the risk of HIV transmission by about 80%—not perfect, by any means, but an effective strategy. For instance, analyses have shown that the famous “ABC” (abstain, be faithful, condom use) in Uganda, which was successful in decreasing the number of new cases of AIDS, probably owed most of its effectiveness to greater use of condoms.

    A second concern is the pope’s position that fidelity within and abstinence outside marriage obviates the need for condoms to prevent the spread of HIV. While such behaviour—though difficult to attain—would certainly help, this position ignores the reality of family life in sub-Saharan Africa. There, much of the spread of HIV occurs within, not outside, marriages, from infected husbands having unprotected sex with their wives. If condoms are not available, these women are forced to make the impossible choice between refusing to have sex with their husbands (and risking abuse) or consenting to sex (and risking HIV infection).

    Some argue that critics of the Catholic church’s position on condom use are wrong when they say that it will be likely to lead to a greater spread of HIV. They say that anyone observant enough to follow the church’s teachings on condoms will also adhere to its policies on sexual abstinence before and fidelity within marriage. I’m not sure where the evidence for this position comes from; I can’t imagine that many Catholics are any different from many Jews or Muslims in selective observance of commandments. Furthermore, this position completely ignores the pope’s influence on non-Catholic Christians and others.

    Others state that if Catholic rules about condom use were an independent risk factor, then African countries with a higher proportion of Catholics would have higher HIV infection rates, which they don’t. But we know that correlations, or the lack of correlations, cannot be accepted as arguments for or against causality. And this view certainly discounts the hugely important effect of the many wonderful Catholic missionaries who provide health care and social services throughout Africa and the developing world, regardless of the local religions, and who cannot advocate condom use.

    One possible approach to the seemingly irresolvable conflict between condoms and religious dictums might be to separate the disease prevention attributes of condoms from their contraceptive effect. There is precedent for this, at least in the United States: many Catholic hospitals and doctors here prescribe oral contraceptives to women not to prevent pregnancy but instead to prevent heavy, painful periods. So it wouldn’t be too much of a stretch to imagine the Catholic church tacitly condoning condom use as part of an overall disease prevention programme to decrease the spread of HIV, even if only within marriages.

    That’s where my childhood memory kicks in. We could advocate using prophylactics in the dictionary sense of the word I learnt when I was 6—preventing disease instead of babies.

    The pope’s job is to be the spiritual leader of the world’s Catholics. It would be a true blessing if he could do that without advocating policies that endanger the health of some of the world’s neediest people.

    Notes

    Cite this as: BMJ 2009;338:b1217

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