Condomologist

all things condoms

Is the Pope right? No. And neither is Mr. Harvard.

Posted by Condomologist on April 6, 2009

Ever since Pope Benedict stirred the condom pot and struck up a worldwide controversy with his comments about condoms aggravating the problem of HIV, the rhetoric has been spewing on editorial newspaper pages, from foreign governments, from just about anyone who has an opinion on church doctrine, public health, the merits of the words of the Pope — heck, anyone who heard the news. So I waited a couple of weeks, took a deep breath, listened intently amidst the fracas, to help make sense of the repercussions and validity of the argument. In general, it seems wise to lend an ear to some of the saner, more rational thinkers in the middle of the political spectrum — of which there are a few — but this time the feedback has been fairly black and white. The Pope’s a dangerous, stupid liar who supports the death of innocent people from AIDS, scream the stalwarts on one side. The other side, those defending the Pope with any intellectual seriousness, tell us that, in fact, what the Pope told us — and we know his response was well thought-out, because he chooses the questions beforehand which he later addresses — is backed by science, that condoms do aggravate the problem of HIV/AIDS. Okay, not every argument was clear-cut for or against, but a marked polarity seemed to run through the general sentiments. Through it all, two things remained clear to me: Science is pretty clear that condoms used among two partners, one HIV+ and the other HIV-, will greatly reduce the transmission of HIV; and just about everyone who defended the Pope kept quoting this dude named Dr. Edward Green from Harvard to support his argument. And so it warrants a good look at what Green actually says, what it means, and how that relates to the Pope’s words — but first, let’s clear a few things up.

Any honest discussion of the Pope’s argument first requires admitting that, at the very least, the Pope owes a more thorough explanation to the world if we’re to believe his comments were simply reflecting the conclusions of Dr. Green. A simple statement would go a long way towards calming the critics — especially the more angry ones — something like, The Catholic church does not support condoms as a means of contraception, and we do not condone any form of homosexual behaviour [implying anal sex for pleasure is not even a topic to be discussed], but if two men or a man and a woman are engaging in sexual intercourse and one partner is HIV+, then condoms will in fact reduce the likelihood that HIV will be transmitted to the uninfected partner. And then he could go on to say that he still felt promoting monogomy and abstinence before marriage — as the Church feels is what’s right and the only sinless choice — is the best way to reduce the spread of HIV in Africa. Until then, as far as I’m concerned, Dr. Green’s argument becomes moot, because we’re arguing about two different things. Even assuming one can amend a quote — as the Vatican chose to do after the Pope’s initial response — something curiously bizarre in and of itself, the Pope still risks doing harm without clarification that condoms do not “risk” aggravating the problem of HIV on an individual level, something Dr. Green (doctorate in  anthropology from Catholic University) acknowledges pretty clearly in his recent Washington Post editorial. For example, some of the more eloquent, toned-down criticisms of the Pope focused on examples where an uninfected woman is married to a man who is HIV+ and the need for them to use condoms if they’re engaging in sexual activity; how can the Pope not side with the use of life-saving protection in such a case, they ask? And what gets lost in these discussions is the fact that the Church must soldier on with an anti-condom stance regarding disease/infection prevention simply to adhere to its long-stated belief that artificial contraception is intrinsically evil and anti-life. So my real question is, Why does Dr. Green have the Pope’s back? Does he really believe that what the Pope said about condoms aggravating the spread of HIV is simply a reflection of Green’s studies and conclusions? I’ll take him seriously, but then let’s take a look at some of what he’s said over the years. (And again, let’s remind ourselves that literally almost every argument made of late in defense of the Pope quotes or paraphrases Dr. Green’s Catholic News Agency interview — with its shoddy quotations and attributions — or his Post editorial.)

First off, Green’s general argument — and the one most often cited and generally accepted — is that in Uganda, HIV/AIDS percentages went down drastically in response to the government working to promote across all public sectors of society — so that the message could be distributed adequately through religious, educational, governmental institutions, etc. —  abstinence, partner reduction and mutual monogomy, but condoms also as the “C” in the “ABC” approach (1. Abstinence, 2. Be faithful, 3. Use condoms if you can’t accomplish the first two.)  His 2003 book Rethinking AIDS Prevention, is seen by some as a landmark publication in the way we view HIV/AIDS prevention in Africa, but on his Harvard website page, in the summary of the book nowhere does it mention anything about condoms aggravating the problem. And in his editorial, he repeatedly talks about the lack of evidence that condoms work as a primary intervention to stem the HIV epidemic in generalized African populations; this is a fair argument to make — that throwing millions of condoms to a culture not accustomed to them will not work alone — but nowhere in his editorial does he dare make the argument that condoms aggravate the problem. This is an important distinction. The closest he comes to making such a case is in a very thoughtful piece he wrote in 2003 called “Culture Clash and AIDS Prevention” in which he writes that “countries with the highest levels of condom availability (Zimbabwe, Botswana, South Africa, Kenya) also have some of the highest HIV prevalence rates in the world.” But there is no exploration as to cause and effect. For example, might there be the most condoms there because the HIV rates are so high? Might there be more condoms available because of their geographical relationship to donor nations? Might the proximity of 3 of those 4 countries — all except Kenya border one another — play a part in their respective exceedingly high HIV rates and thus the attention those nations receive? It’s illogical to imply that more condoms = more HIV, when there are numerous other factors at play, many of which he discusses in the piece. And in fact, at the 2004 International AIDS Conference, Green clears things up a bit: “There may be no causal connection between the availability of condoms and levels of HIV infection, but…there’s little evidence at the national level in Africa that more condoms resulted in less AIDS.”

I’m torn, because I want to support Green, because it doesn’t even require factual evidence to support the idea that condoms alone don’t solve any problems. And like he says, there’s nothing in the fidelity and abstinence message that infringes on anyone’s rights — as he implies some might see as an obstacle to behavioural change interventions — and the lefty liberal folk need to do a far better job in learning how to promote these messages in order to be most effective. He’s right that the sexual health people are too damn scared of the word abstinence — even in the context of abstinence-plus, meaning comprehensive sex ed, but abstinence if possible — and he’s correct that we in the sexual health world are suspicious of the religious right and their talk of behaviour change. With good reason: their track record in the States simply isn’t that good, and there’s no proof that abstinence-only-until-marriage programs — something very different than abstinence-plus-condom education — are more effective than the alternatives by any measure. But again, he makes the valid point that we must be culturally sensitive, and approaching the African HIV epidemic with the same risk reduction mindset we may take here in the states — for example, use mutual masturbation or oral sex instead of anal sex to reduce the risk of contracting or transmitting HIV — can miss the point entirely. It makes sense for those on the left to seriously consider that behaviour change is possible, and personally I know I don’t do a good enough job of exploring this possibility. It’s not wrong or condescending or moralizing to bluntly, honestly state that reducing one’s number of sexual partners or staying faithful (even within a polygamous marriage) reduces your chances of contracting HIV. It’s the truth. But the truth has some grey areas in this case, something the Church is not known for (though one can make a strong argument that the Catholic Church should be commended for its absolute anti-condom stance,  for sticking to its guns no matter the facts on the ground), and so what I can’t wrap my mind around is why Dr. Green chooses to defend the Pope. All I can conclude is this is best reaction (to get attention?) to the reactionaries vehemently criticizing (his?) Pope Benedict, while he must know his statements will be distorted by conservatives to call liberals stupid for denying the facts. His argument simply doesn’t follow given what the Pope did and didn’t say.

The BBC has a very good analysis of the issue (which I linked to already) much of which echoes some of  my points above and makes clear the need to accompany any condom promotion with culturally and geographically sensitive education and marketing . Thomas Reese of Georgetown, while sadly and dismissively exculpating the Pope of any culpability — because who listens to the out-of-touch Pope anyway? — at least argues the Vatican would wisely step up to the plate and advocate for condoms on an anti-killing platform. The World Health Organization makes clear that there are many complex gender and cultural factors to overcome, but that condoms have played a decisive role in HIV prevention efforts across the world, including in Uganda, so often cited by Green. The counter-argument to Green as it relates to Uganda (and the one cited by the WHO) is a Guttmacher Institute report from 2003  that pretty unequivocally points to increased condom use across unmarried male and female populations in Uganda, and I could not find anywhere Green disputes this study; he would simply argue that the HIV rates had largely declined before the large-scale condom promotion began in the mid-90s.  But then it’s not a counter-argument at all, because Green never makes an anti-condom argument anywhere. He just oddly chooses to support the Pope with his misguided logic. Or does he? He very ominously continues to point out that condoms lead to “risk compensation,” meaning when people believe they’re safer by using condoms some of the time, they’ll actually engage in riskier sex. It is this last point, one he seems to have little evidence for, that is pounced on by the conservative wing of the debate, and that’s unfortunate given the lack of any real data. One thing he’s very clear to point out is that condom use as a targeted HIV prevention very clearly works, in particular for sex workers in Thailand and Cambodia; but since HIV is largely transmitted through casual heterosexual sex in Africa, condom promotion can’t be the primary message. Fine, but let’s look one last time at what Green says as part of a panel at the  2004 International AIDS Conference: “I feel that condoms have a role to play as a means of protection, especially in couples who are HIV-positive, but it cannot be the main means of stemming the tide of AIDS.”  And he goes on to tell us that while the A and B were far more prevalent in the general population than condom use at last sexual intercourse, “…condom use has become quite high among those who need the most, namely those relatively few who are still having multiple partners. As a matter of fact those going to sex workers, although not many Ugandan men reported paying for sex, but condom use was very high among them and 95% or so.” I’m no expert on this stuff, no advanced degree, haven’t even read Green’s book…but it’s a fairly evident study in contrasts to find him telling us one sentence that condoms aren’t that much of a factor in decreasing the spread of HIV…but wait, they have a role to play…and oh yeah, condom promotion really does work in targeted populations…but last thing, the Pope is right when he says condoms aggravate the problem. Maybe it is relevant that his doctorate is in anthropology and not public health, because one thing we learn in the HIV/AIDS world is that while it’s important to identify as many positives as possible — so folks know their status and hopefully won’t put others at risk — the real key is reaching that one person who is having sex with many partners and thus spreading around town. So it seems rather relevant that condom use was so high among those with multiple partners and those paying for sex — not just something to be discounted. All this said, it’s kinda hard not to question this Harvard doctor’s conclusion and motives.

I really really wanted to give the Pope the benefit of the doubt on this one. I wanted to believe there was a silver lining — and maybe there is in the debate he stirred up — but it’s proven hard to find one. I wonder what the conservative talking heads would’ve found to back up the Pope’s indefensible anti-condom stance if not for one rogue  self-described liberal Harvard researcher who seems only to have mastered the art of duping us all into thinking Catholic craziness has some merit this time. Nope, sorry. I call your bluff. Condoms aren’t the only answer. Far from it. But you all need better data to make your argument come anywhere close to sticking this time.

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3 Responses to “Is the Pope right? No. And neither is Mr. Harvard.”

  1. Dare said

    Well researched, perceptive, insightful, sophisticated, and beautifully argued. Quit your job and write full time.

  2. bc said

    risk vs benefit – that is the bottom line. Even if condom use does promote more risky behavior, does the data really suggest that there are more cases of HIV contracted by condom users who occasionally “forget” to put on their rubber compared to the number of potential HIV exposures prevented by condom use? All agreed -except the pope – that condoms serve a purpose that they are effective–but wait they may occasionally lead to unprotected behavior so people shouldn’t use them at all, what!!!

    what can you say, you kept an open mind but the common sense just isn’t there–sorry Pope B not this time.

  3. […] by Jonathan on May 18, 2009 There’s no doubt the Pope riled up emotions with his anti-condom stance a couple months back. But nothing I’ve seen or heard so far has the potential to stir up the […]

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