Central America
AIDS: A Sign of our Times
In September 2001, El Salvador hosted the Latin American Catholic Theological Consultation on AIDS to reflect on an undeniable sign of the times in the light of God’s word.
Pascual Ortells
"Once upon a time there was a body that was protected by a warrior…." As the narrator tells the tale, a priest and two young people act it out. "Diarrhea came along and the warrior repelled it. Then came tuberculosis and the warrior defeated it. The warrior conquered any illness that wanted to overpower that body and so the body remained healthy. But one day a virus came along and started flirting with the warrior himself; it overpowered and began to weaken him. After a few years, when the warrior was very weak, the diarrhea and the tuberculosis returned with a great hoard of other illnesses. They took hold of the body and didn’t let go of it until it died..."
Maryknoll missionary Mary Annel explained that she and her team act out this story to show people how the human immunodeficiency virus (HIV), which causes AIDS, acts on the human body. It was an appropriate way to open the Latin American Theological Consultation on AIDS, organized by Caritas International and held in San Salvador on September 3-7, 2001.
Catholics in the front lineUS priest Robert Vitillo, one of the presidents of Caritas International’s working group on AIDS, told me that for 10 years he and the group’s other president, British priest Julian Filochowski, had wanted to promote a dialogue on the HIV-AIDS issue with theologians and pastoral agents in Latin America as they had already successfully done in Africa. The aim of the consultation in El Salvador was thus to promote a debate on this complex, painful and challenging reality among theologians, priests, nuns and laypeople committed to some form of action against the epidemic as well as with people who are living with HIV or already in the AIDS phase.
"It’s good to hold this reflection among people of faith in a region that acted like a midwife in supporting the commitment in the last decades of the 20th century known as a preferential option for the poor," said Filochowski, who is proud to have been a friend of Monsignor Romero.
Personally, the most immediate and stimulating fruit of this consultation was to discover that the Catholic Church in Latin America already has women and men in the front line fighting against AIDS: working on prevention with vulnerable groups and providing care for people with HIV. I’ve been working in this field for 10 years and didn’t know about these efforts, so I hope this discovery will be of interest to others, too.
Bernardo Vergara in ColombiaThe efforts of Father Bernardo Vergara to care for HIV sufferers and fight against discrimination are one such example of the Christian presence in responding to AIDS’ challenges. Since 1989, Father Vergara has been committed to caring for adolescents and young people who are living with and fighting HIV infection. He started out visiting Bogotá’s hospitals and was struck by how many of the patients were suffering from opportunist illnesses related to this infection. When they were released, they had nowhere to go because their families had rejected them either because of their illness or their homosexuality, or both. He started to "exercise compassion" with eight youths convalescing in a rented house that they turned into their home.
On realizing they were facing a growing problem that nobody was dealing with well, the priest and his team of collaborators decided to form the Eudes Foundation at the service of children living on the street who are sexually exploited. The foundation was named after French priest and saint Juan Eudes, who in the 17th century cared for those suffering from the Black Plague. At the beginning, Vergara’s team used public health methods such as surveys and sporadic visits, but the results were not good. They then tried another approach, using the kids’ language and lifestyle, with Vergara becoming one of their street-mates and even passing himself off as a sexual client to win their trust.
The Eudes Foundation currently has several houses sheltering 22 children and 45 young people. Each one includes educators—he calls them "re-educators and therapists"—who help the residents resolve their legal problems, reconcile with their families and, when possible, arrange for them live with some member of their family. If they have no family or cannot go back home, they stay in the house. The foundation has a telephone line known as the "lifeline," which is coordinated with their outpatient program in which a doctor, a psychologist and a person living with HIV all offer advice and referral to the young people, seek to reunite them with their families, or, if they choose, admit them to one of the houses.
Father Vergara has witnessed the sexual exploitation suffered by children, adolescents and young people of both sexes in Colombia. As he puts it, "AIDS is part of a package; it doesn’t come alone. It is always accompanied by unfaithfulness, a multiple relationship, addiction, crime, rape, irresponsibility or a sexual orientation—homosexuality or transvestitism."
Thanks to his work, many people now support the Eudes Foundation. While Nicaraguan ambassador to Colombia, Ernesto Salmerón offered his services as a voluntary pediatrician and encouraged a group of colleagues—among them Spain’s ambassador Carmelo Angulo, later the UNDP representative in Nicaragua—to build a palliative care unit for pediatric AIDS cases. The unit provides 30 girls and boys with antiretroviral therapy and works with pregnant women to prevent perinatal HIV transmission. The women receive AZT throughout their pregnancy and, so far, there has been no new HIV infection among the babies. The women with HIV who attend the Foundation have a dressmaking workshop where they work for wages with social security benefits and fundraise by organizing bazaars, fashion parades and raffles.
Dee Smith in GuatemalaAnother example of the Christian presence in this struggle is Maryknoll missionary Dee Smith, who works on AIDS in Coateque, near the Guatemalan border with Mexico. A doctor, she started treating people with tuberculosis in a hospital in Quetzaltenango, where they carried out the HIV antibody test, better known as the AIDS test. When they discovered that 75% of those with tuberculosis and HIV were from the coastal region near the Mexican border, they moved to that area and now work with rural communities providing education, support for the families, counseling and the AIDS test. Many of the people with HIV they have cared for are not Guatemalans but rather emigrants from El Salvador, Honduras or Nicaragua, who spent a lot of money to leave their country, were hit by this misfortune and are ashamed to go back.
From 1975 to 1989, Dr. Smith had lived in Kenya, where she lost several friends to a strange disease they called "slimdisease," because it left those affected extremely thin. By 1982, this disease had been given the name AIDS in the United States, where it was previously known as the "gay plague." Although accelerated weight loss is frequent among poor people living with HIV in poor countries, it is not the only symptom of AIDS or even its characterizing one, as alcoholism, for example, can also cause an exaggerated loss of weight.
In 1990, when Dr. Smith was working as a volunteer in a New York family health center that cared for people with HIV, she and Dr. Mary Annel started up the Maryknoll AIDS Taskforce, whose mission of working with the most marginalized people coincided with that of their order. This network consists of around 300 Maryknoll sisters and priests deployed throughout the world who are dedicated one way or another to preventing HIV infection, caring for people suffering from opportunist illnesses or with AIDS and reducing the discrimination related to this epidemic.
Dr. Smith sees her current work in the Life against AIDS Project, where people find a space in which they are not judged, as an opportunity to come closer to God that requires her to cast aside all of her prejudices.
The Life against AIDS Project is implemented in the name of the National Health Commission of the Guatemalan Bishops Conference and is the Catholic Church’s response to the AIDS problem. The project needs a lot of support from the Church, but that support is limited and most of the work is done outside of Catholic structures. In fact, the project changed its name several years ago from the AIDS Project to Life against AIDS because the priests made jokes and said, "Here come the AIDS sisters." The project team wants its work to be "the extension of the work of Jesus Christ by giving life in plenitude to those most marginalized and impoverished by their illness."
Mary Annel in El SalvadorDr. Annel has been directing the Archdiocesan Team against AIDS in San Salvador since 1993, with the support of certain parishes and priests. The team visits communities giving one-day workshops on AIDS, using participatory techniques and small group discussions. Their work is inspired by the teaching methods of Paulo Freire.
The 20 male and female volunteers in the team offer their support to people living with HIV, talking to them about natural medicines and nutrition and visiting the houses of people with HIV if they are willing to receive them. Dr. Annel goes to a "clinic" in a parish center in San Salvador twice a week to diagnose and treat opportunist illnesses. A self-help group meets in the same center, a safe and friendly environment in which to talk about their problems and needs and encourage each other to push ahead with their dietary needs, negotiations with doctors and raffles to finance the group’s activities. Dr. Annel obtains antiretroviral therapy for a few people, thanks to her solidarity network in the United States.
This pastoral work was approved in 1994 by the then archbishop of San Salvador, Arturo Rivera y Damas, but when he died, the Catholic hierarchy’s support for the team changed, and relations reached a low point that could have been avoided through dialogue. The conflict started in 2000, when Salvadoran NGOs working with AIDS published a sex education manual with the logos of all of the organizations in the network, including the Archdiocesan Team. The current bishop, Sáenz Lacalle, was annoyed that the archdiocese had been involved in this publication without his authorization or consent—although the text was similar in content to any primary school natural science book—and he managed to get the manual pulled out of circulation. As time went on, the tone of the declarations by both sides made the conflict even more bitter, and the bishop prohibited the team from using the title "Archdiocesan," recommending that it become an NGO as the hierarchy did not recognize its work as that of the Catholic Church.
Work in Honduras gets the cardinal’s backingMeanwhile, in Honduras, a homosexual dentist returned to his hometown of El Progreso in 1985 after having lived in San Francisco for several years. His was the first recognized case of AIDS in Honduras. Since then, Honduras has registered an average of 150 deaths per month of people infected by the virus, a total of some 30,000 people. Of every 10 AIDS cases recorded in Central America, 6 live in Honduras.
The Good Samaritan Pastoral Mission and Caritas encourage the empowerment of people living with HIV, and enjoy the backing of the Bishops’ Conference in Honduras. In 2001, they contributed to the Meeting of the National Association of Hondurans Living with AIDS, on which occasion, Honduran Cardinal Oscar Andrés Rodríguez said: "You have to defend yourselves, and you therefore need to be organized. That way your voices will be heard, spaces will open up for your participation and the services to which you have a right will become available to you. We want this first meeting to be a real starting point to discover in yourselves the strength necessary to allow you to promote and defend your lives. You will always have our support and our prayers so that the God of life is your comfort and your strength."
Catholic pioneers "under suspicion"The Conference of Brazilian Bishops has a national commission on sexually transmitted diseases and AIDS; Caritas has opened shelters, projects and other ways of working with AIDS both in prevention and attention in Costa Rica, Haiti, Mexico and Colombia; and the Catholic agency CAFOD finances care and preventative education projects in Bolivia and Peru. And this list is far from exhaustive.
Those working in these projects sometimes find themselves in the same position as those whose faith led them to become active in the Communist Party during the 1970s. In the party they were seen as "the believers" and in the Church as "the communists" and in both camps were viewed with a mixture of curiosity and suspicion.
The "AIDS effect" in the fight against povertyAIDS programs are justified by a number of factors, as the illness threatens not only public health but also human rights and development. The figures from the latest UNAIDS report speak for themselves: 40 million people in the world are living with HIV or are already in the AIDS stage, of which 44% are women and almost 2.7 million are under 15. In 2001 alone, there were 5 million new HIV infections and 3 million people died from AIDS.
Other, perhaps more serious, problems—such as hunger, climatic change, illiteracy and the housing deficit—do not take anything away from the seriousness of the HIV pandemic, which was recognized by the UN Security Council in January 2000 as a direct threat to national and international security. Among other reasons, this is due to the mutual reinforcement dynamic established between AIDS, poverty and lack of information. The HIV epidemic both aggravates and feeds on poverty. If the "AIDS effect" is not taken into account, the search for alternative ways of climbing out of poverty—both personal, such as migration and sexual work, and national, such as maquiladora assembly plants and tourism—could create even more favorable conditions and settings for the epidemic’s propagation.
The epidemic in the regionInaugurating the theological consultation, Julian Filochowski reminded those present of the words of World Bank president James Wolfensohn, quoted in The New York Times in January 2001: "Epidemics are more efficient than wars in destabilizing countries." He also quoted UN Secretary General Kofi Annan’s report to the Special UN General Assembly Session on AIDS, highlighting that the Central American countries, "already ruined by armed conflict, environmental destruction and exclusionary economic growth, have experienced a growing rate of infection, particularly among the poorest population sectors and among women."
It is calculated that some 1.8 million people are living with the infection in Latin America and the Caribbean, where different patterns of HIV transmission have in fact produced various AIDS epidemics. This figure includes the 190,000 people who contracted the virus in 2001. The Caribbean is the second most affected region in the world, after Sub-Saharan Africa, although its rates are significantly lower than the high African ones.
Four of the ten highest rates of HIV infection among the adult population of Latin America and the Caribbean belong to Central American countries: Belize, Honduras, Panama and Guatemala. The other six in the top ten are Caribbean countries. The other Central American countries—El Salvador, Costa Rica and Nicaragua—come in at 14, 16 and 23, respectively, in the Latin American list.
Central America registered 21,251 AIDS cases up to May 2000, half of which (10,866) corresponded to Honduras. The different categories of transmission during that period were as follows: heterosexual 72.8%, homosexual and bisexual 11.8%, perinatal 4.8%, transfusion 0.9%, intravenous drug use 0.6%, blood derivatives 0.2%, unknown 8.7%. In other words, around three-quarters of the cases registered in Central America were the result of sexual relations between men and women. In Costa Rica, Mexico and some parts of the Andean region, however, sexual relations between men represent the main route of HIV transmission.
The wide access to antiretroviral treatment in countries such as Brazil, Argentina and Uruguay has not extended to most other Latin American countries. In Central America, only Costa Rica and Panama offer antiretroviral treatment to people living with HIV and it is estimated that this treatment is received by only 5% of the population that needs it in the region as a whole.
A tragic sign of our timesThe theological consultation created a space in which to reflect on the theological reasons that, along with other ethical, scientific, political, economic and humanist ones, make sense of the Christian presence in this area.
Theologically speaking, AIDS is a sign of our times. Seen from the theological perspective, whose starting point is the attempt to discern the word of God from the reality of the oppressed, the Church in Latin America should listen to and announce the signs of the times. Filochowski recalled the words of Monsignor Romero: "The word of God cannot be separated from the reality in which it is proclaimed. It would not be the word of God and the Bible would be only a pious history book. It is the word of God because it illuminates, contrasts, rejects and praises what is happening in our society today."
AIDS is what is happening today. It is a contradictory, tragic and undeniable sign of these times. This confirmation is fundamental, particularly in those places where the epidemic is most silent, or most silenced. According to Salvadoran theologian Jon Sobrino, one of the consultation’s advisers, throughout history God has recurrently made his presence felt through signs. And just as reality defies theory, signs of the times throw up new challenges to doctrine. Therefore, this new sign called AIDS requires reflection on how to build a new theological line of thought that is faithful to both the doctrine and this reality.
Too little theological reflectionDefense of life is another line of theological reflection related to AIDS. Filochowski sustains that the Church’s primary responsibility is to defend the life of each person: "It is precisely because the HIV pandemic threatens the very survival of individuals, families and communities that many are now reflecting on the extent to which the Church’s pre-eminent vocation of defending life is pushing it to respond to this crisis."
Liberation, the option for the poor, justice and compassion are just some of the biblical and theological approaches to AIDS and its impact on globalized society. Nonetheless, some theologians feel that there is too little theological reflection in response to this challenge. Father Leonard Martin, professor of ethics at the state university of Ceará, Brazil, sees this shortcoming as a challenge that neither European theology nor Latin American liberation theology have really taken up. This lack has not helped raise awareness over the AIDS problem and from a gender perspective has even blocked understanding of women’s particular vulnerability to the epidemic.
Justice, not punishmentIn the area of moral theology, Father Enda McDonagh, a professor at Maynooth College in Ireland, feels that "the primary theological response of a disciple of Jesus and someone who promotes the Kingdom of God is to create a just society." In the case of AIDS, he believes that the virtue at issue is not chastity but justice, understood not only as just distribution but also as the transformation of structures to achieve a just society.
Summing up the limitations of moral theology before the Second Vatican Council, McDonagh noted that it focused on the individual: "it is legalistic, casuist and obsessed with sin." Post Vatican II, things have changed; moral theology has sought its roots in the scriptures and is attentive to the dynamics of people in their communities, which is why it stresses social justice and not just the individual. In conclusion, McDonagh stated that "opting for the poor is the new starting point for faith, hope and love. However, the reality of evil—and this includes AIDS—reduces the sense of faith, hope and love."
Deep rootsIf we organize the causes of the epidemic according to a tree-like model—as is done in the "logical framework" planning method—we find that human behavior and the risk of infection that such behavior entails form the superficial roots. The deeper roots of the epidemic have to do with social injustice and vulnerability, involving poverty, gender subordination, discrimination, sexism and unfair exchange in the economic market.
Given that the most frequent form of transmission is sexual, the inequity in gender relations greatly helps propagate the epidemic: "We are slaves to mental structures that stop us from relating to others as equals." Furthermore, sexism degrades what McDonagh terms the "spiritual corporality" that expresses the presence of human beings relative to themselves, others and God.
The condom controversyCondoms were mentioned right from the outset of the consultation. According to Filochowski, "the leaders of the Catholic Church and of other religions protested about the mass promotion of condoms in prevention programs that did not discuss other methods of prevention based on values. The Church leaders’ problems included concern about the promotion of extramarital sexual relations and making sexual promiscuity ‘safe.’ It is no surprise that many saw a link between these concerns and the Church prohibition of the use of artificial forms of contraception."
In an article in the April 2000 edition of L’Osservatore Romano, Bishop Jacques Suaudeau argued that the Catholic Church’s firm and public position against the use of condoms has been misinterpreted and that people believe that the Church opposes efforts to prevent HIV, which is false. Father Vitillo told me the same. "There is a certain prejudice against the Church and its organizations," he said, " because many doctors, many AIDS experts just want to focus on the problem of condoms. In my personal opinion, this is not the only problem, nor the only measure to prevent the virus. I believe that the Church’s teachings on abstinence and marital fidelity are important and that these virtues are safer than using the condom."
Responding to "rigorist" moralsReferring to the Catholic teaching that extramarital sex is a sin, Leonard Martin stated that those who follow the Catholic doctrine on marriage, consecrated chastity and chaste courtship can accept such teaching and assume such values even if they fail to apply them at times. Many people, however, do not find such reasoning realistic for various reasons and see no sense in the messages emitted by theological morals. This is the danger of what Martin terms "rigorism."
Many male and female adolescents find masturbation acceptable. Other people believe that casual sexual relations are acceptable between consenting adults who protect themselves. So how can an intermediary point be established? The rigorous nature of the doctrine tends to produce the counterpart of moral relaxation, due precisely to the lack of any intermediary space. Theology has to present goals that are attainable among a plurality of subjects, cultures, contexts and paradigms. According to Martin, it is a question of doing "a small act of good in a malignant setting" and doing "the good that is possible in perverse circumstances."
Condoms: Hygiene or contraception?The Catholic hierarchy has avoided the challenge of trying to reason with those who disagree with it, and instead just repeats its positions, which are only understandable in its own particular frame of reference. Furthermore, it does not use what Father Martin terms the "missionary methods" of cultural insertion, listening and searching for common ground.
One effort to put this polarization right is the dual effect argument, according to which the condom is considered an instrument for preventing sexually transmitted diseases rather than a contraceptive. Its aim would therefore be prophylaxis rather than the prevention of pregnancy. The condom is thus seen as a hygienic product that protects against fungi, bacteria and viruses transmitted during a penetrative sexual relation. Seen in this way, condoms also protect the sexual relations of stable and married couples. The use of condoms would therefore not be an offense against the institution of marriage. However, it does have to be recognized that this is not the point of view normally held by Catholics, who consider condoms a contraceptive, not to mention a proof of infidelity.
Another line of reasoning on the issue of condom use is the typical moral theology argument of the lesser evil: "If you’re going to sin against the sixth commandment not to fornicate, then don’t sin against the fifth, not to kill." Put this way, which is precisely how many of those in favor of this line of reasoning put it, it sounds like a bad joke. It is no laughing matter, however, because it conceals both a prejudice and an error. The prejudice consists of believing that all infected people who have sexual relations without a condom are trying to kill their sexual partner, which is not true. The error consists of ignoring the fact that 90% of those infected do not know that they are. And as we learn in the catechism, if there is no intention, there is no sin.
UNAIDS and the Catholic ChurchMonsignor Suaudeau proposes that HIV prevention should not be limited to promoting condoms. "It should be raised to another level," he said, "and aimed at the real social, economic, political and moral roots of the epidemic." This is, in fact, a position currently shared by UNAIDS.
There has been a growing rapprochement in which the Caritas International working group has played an important role. According to Father Vitillo, "We in Caritas were able to raise awareness a little on public health aspects, even among members of the United Nations. At the beginning of 1987, the United Nations and most governments did not talk about abstinence and fidelity within marriage. Once, the World Health Organization director at the time, Mr. Makajima, called a meeting with us and asked me: ‘Why is the Pope against condoms?’ And I asked him: "Why are you against marriage?’"
When the WHO director protested that he was not, Vitillo told him that the United Nations’ messages and information "never mention marriage or abstinence and these are also effective AIDS prevention measures." Since that meeting, Vitillo feels that UNAIDS has a better understanding of the Catholic Church position and has gradually changed its messages. Just as the Catholic Church has influenced the public health messages on AIDS by plugging away with its own point of view, however, the pandemic is now challenging the Church to hold an open discussion about sexual rights and the anthropological and ethical aspects of sexuality.
John Paul II: "Everyone should be recruited"In his exhortation to the 1995 Synod of African Bishops, Pope John Paul II proclaimed, "Everyone should be recruited in the fight against AIDS. Echoing the voice of the synodal fathers, I also call on the pastoral agents to provide the brothers and sisters hit by AIDS with all of the compassion possible, be it material, moral or spiritual."
According to Filochowski, pastoral support, as part of the Church’s evangelizing mission, has to help defend the rights and dignity of those living with HIV or with AIDS and to open the Church’s services to effective prevention activities. He recalls that at the end of the 1980s, when he first mentioned AIDS to Brazil’s Cardinal Paulo Evaristo Arns to suggest "an archdiocesan response to the pandemic," he was told that AIDS affected the middle classes, who had resources, and did not merit a priority response from the Church, whose primary responsibility was to respond to the poor. However, Arns did consult his pastoral agents who worked with street children and knew of many AIDS cases among them. This led him to change his mind and since then, he has tirelessly defended people living with HIV or who already have AIDS.
Three bases for accompanimentDuring the theological consultation in El Salvador, Spanish priest José Carlos Bermejo proposed three bases for pastoral work on AIDS, within the framework of a "holistic accompaniment" that tackles the three dimensions of marginalization and exclusion.
The first basis is the economic dimension of the exclusion, including lack of housing, informal work and poverty. In most cases, those affected suffer marginalization due to their limited income or the fact that they live in a poor house or neighborhood, while those already in the AIDS phase are excluded from health services, particularly in poor countries. The second basis is the social dimension of the exclusion, with the absence or fragility of healthy relations of support and of referral points that serve as an underpinning. Many people with AIDS live, agonize and die in the most terrible solitude in an adverse environment, without the company of any relatives or friends. The third basis is the subjective dimension of the exclusion, in which those affected isolate themselves, do not trust in their own strength, lose all hope, undergo identity crises and suffer from low self-esteem.
The hope lies in educationPastoral accompaniment can play a very important role in all three dimensions by creating new foundations. Bearing this in mind, pastoral care can eliminate the "social death" that causes just as much if not more suffering than HIV itself for those affected and their families.
Pastoral accompaniment will thus also have beneficial effects in the field of prevention, because someone living with HIV is a possible agent of new infections, particularly in vulnerable situations of personal crisis or lack of information. It could also become an excellent way to educate the community. And at the end of the day, education is what offers the most hope for success in confronting this painful sign of our times.
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