A matter of life and death

The BBC?s Panorama programme has criticised the Church?s case against using condoms to combat Aids. Who is right? And what do the experts think?

CAN condoms kill? Only if a crate of them drops on your head, seemed to be the conclusion of a BBC programme last Sunday. Panorama, which specialises in hard-hitting investigations, took the unusual step of dealing seriously for 45 minutes with a Vatican document. The fact that the document contained some outrageous assertions which fly in the face of science may have had something to do with it.

The document, ?Family values versus safe sex?, was a scientific paper issued in January by the president of the Vatican?s Council for the Family, Cardinal Alfonso L?pez Trujillo. He had been stung by the outrage following a Panorama programme last year (?Sex and the Holy City?) into issuing scientific data in support of his claim on that programme that condoms were not reliable weapons in the battle against Aids and should carry a health warning to that effect. This was because the HIV virus was shown to have passed through condoms, which as a result had a 15 per cent to 30 per cent failure rate; ?safe sex? was therefore a misleading term, he said.

The problem with the paper was that it conflated the infinitesimal risk of porosity with the failure in condoms arising from accidents, slippage, breakages and other mishaps. In fact, when condoms are used ?properly?, as they were in a legalised Nevada brothel on the programme, they are almost totally effective as barriers to the Aids virus. Studies in San Francisco show that if 100 uninfected people have sex using condoms with infected partners for a year, only one of them will get the virus. As the programme showed ? and the experts I spoke to this week all agreed ? condoms are simply not porous; worse, the scientists the cardinal attempted to harness to his case appeared on Panorama to accuse him of misusing their evidence.

So why, after so many years of silence on the question of condoms and Aids, should the Vatican?s first public pronouncement ? a scientific paper with 87 footnotes which took three months to prepare ? be so shoddy as to make it risible? If this is what the Vatican resorts to, many viewers will have concluded, the Church?s case against condoms must be suspect.

But that would be the wrong conclusion. Many experts agree with the Church?s scepticism about Aids campaigns based on promoting condom use. Four years ago Dr John Richens, who lectures in the Centre for Sexual Health and HIV Research at the Royal Free and University College Medical School in London, published an important article in The Lancet in which he questioned the theory of risk being used by international agencies. Prophylactics, he told me this week, are ?a unique weapon? in dealing with Aids, which among highly infective groups (prostitutes in Africa, for example) reduces transmission rates by about 90 per cent. But he agrees that ?it is fair to sound warnings about condoms as a solution?, partly because ? as the cardinal asserts ? condoms encourage risky behaviour.

?The model of risk I believe in would say that if you protect anybody from the negative consequences of risky behaviour, then you?re encouraging risky behaviour,? Dr Richens says. He believes people are ?much too coy about saying what impact condoms have had on sexual behaviour?. In the West, the removal of the fear of unwanted pregnancies through contraception has led to the age in which people have their first sexual encounter coming down year on year; in Africa, the ?condomisation? campaigns are likely to have the same effect, which partly at least explains why Aids transmission rates have gone up as condoms are promoted.

But Dr Catherine Hankins, the chief scientific adviser for UNAids, believes it is unfair to extrapolate from this fact that condoms are ineffective against Aids. In order to defeat the epidemic, she says, 60 per cent of ?risky sex acts? ? which she defined as ?sex with a casual partner or with a married partner if they have other partners? ? would need to be covered by condom use; currently, the coverage in sub-Saharan Africa is about 18 per cent, which works out at about 4.6 condoms per man per year. But even if it were possible to cover the continent in latex, Dr Richens?s risk model suggests that HIV rates would remain unchanged.

Experts involved in the fight against Aids in developing countries whom I spoke to this week were critical of the bias among international agencies in favour of ?technical solutions? ? mainly condoms ? to Aids. Condoms, says Gillian Paterson, a writer on Aids and adviser to Christian Aid, ?should not be the first resort in combating Aids?. She points to the example of Uganda, the country which has had the most dramatic decline in HIV infection rates ? from 21 per cent to 9.7 per cent among pregnant women between 1991 and 1998. In 1992, the major religious organisations in Uganda ? Anglican, Catholic and Muslim ? became involved in Aids prevention, promoting fidelity and abstinence rather than condoms. Many international agencies were sceptical; but the approach was favoured by President Museveni, who emphasised a return to what he called ?time-tested cultural practices that emphasise fidelity and condemn extramarital and premarital sex?. The government programmes do not exclude condoms, but the level of usage among Ugandan males is lower than in neighbouring countries. The Ugandan model, Paterson believes, shows ?there should be less fatalism about the capacity of young people to change their behaviour?.

Sue Lucas, who ran the UK Non-Governmental Organisations Aids Consortium in the Nineties and is a trustee of the Catholic Institute for International Relations, agrees. ?People do change behaviour ? if they have the knowledge and the choices,? she told me. She believes the Churches can play a vital role in dealing with Aids in Africa by helping communities to take moral responsibility as well as care for people with HIV. The opposite of that approach is ?providing loads of condoms and hoping that this will change people?s behaviour?, she says. Lucas believes the Church ?is ahead of the secular agencies in this respect? and ?doesn?t get the credit it?s due?.

But if church programmes should not promote condoms, should they exclude them altogether, under all circumstances, as the Vatican believes? Lucas and Paterson believe not. They are disappointed that the Church?s stand on Aids is undermined by its insistence that condoms should not be used even by people who resist their message of fidelity and abstinence. It shows, says Paterson, ?a complete lack of compassion for the weak and the poor ? women who are coerced into sex, women who can only get an education if they have a sugar daddy, women who resort to prostitution to feed their children.? For these people, the Church?s invitation to fidelity and abstinence may simply be impossible.

What so many people find incomprehensible is the Vatican?s intransigent opposition to using a condom in any circumstances, despite the views of Catholic moral theologians who have for years pointed to the doctrine of double effect, lesser evil, and the principles of toleration and cooperation as important principles to be invoked in the context of Aids. In the mid-1990s Bishop Rouet of the French bishops? social commission issued a statement appealing to the lesser evil, which received a cautious but considered acceptance by many bishops, archbishops, and cardinals around the world (The Tablet, 24 February 1996).

Bishop Kevin Dowling of Rustenburg, who is in charge of the Church?s Aids policy on the front line of the pandemic, in South Africa, has also publicly called for the condom to be admitted in the context of the real-life choices faced by millions of infected Africans (The Tablet, 9 November 2002). James Keenan SJ, editor of the best book on the subject, Catholic Ethicists on Aids Prevention (Continuum, 2000), has found ?very few theologians who differ significantly? from the view that to recommend condoms in a time of Aids is not to condone contraception, but prophylaxis. To say that a person who refuses to abstain from casual sex should use a condom is neither to condone their behaviour, nor to condone prophylactic sex, they argue; it is to encourage them to take some moral responsibility for the lives of others.

Cardinal Godfried Danneels, the Archbishop of Brussels, expressed this in January when he said: ?If a person infected with HIV has decided not to respect abstinence, then he has to protect his partner and he can do that ? in this case ? by using a condom.? To do otherwise, he said, would be ?to break the Fifth Commandment?, that you shall not murder.

But the Linacre Centre in London this week accused Cardinal Danneels of taking an ?unusual? and ?incoherent? position. ?What Danneels is saying is that sex with a condom is not as grave as endangering life. But he appears to be suggesting the violation of one commandment rather than another,? Hugh Henry, its education officer, told me, adding: ?This is odd advice from a bishop whose primary responsibility is the spiritual welfare of his flock.? Asked which other commandment Danneels appeared to be urging people to break, Henry said it was the Sixth (you shall not commit adultery). Using a condom, he said, ?in failing to honour the fertile structure that marital acts must have, cannot constitute mutual and complete personal self-giving and thus violates the Sixth Commandment.? A migrant worker who goes to a brothel in South Africa should not, of course, have sex; but if he does, Henry appears to suggest, he should not use a condom to prevent giving the woman Aids because his act fails to honour the fertile structure that marital acts must have.

Readers must decide whether it is Cardinal Danneels or the Linacre Centre which is offering the stranger advice.