World AIDS Day: Promoting Awareness and Concern

Message for World AIDS Day
Dr Margaret Chan, WHO Director-General

This year, which marks the 20th anniversary of World AIDS Day, also marks a major milestone in the long struggle against this disease. Well over 3 million people in low- and middle-income countries are now receiving life-prolonging antiretroviral therapy. Such an achievement was unthinkable 20 years ago, when the world was just beginning to comprehend the significance of this disease and its catastrophic impact on individuals, families, and societies.

AIDS is the most challenging and probably the most devastating infectious disease humanity has ever had to face. And humanity has faced this disease, in equally unprecedented ways. The international community has rallied at levels ranging from grass-roots movements to heads of state, from faith-based organizations and philanthropists to research institutions, academia, and industry.

On this 20th anniversary of World AIDS Day, I find it appropriate to reflect on some of these achievements. The response to AIDS changed the face of public health in profound ways, opening new options for dealing with multiple other health problems. It showed the power of determination to overcome seemingly insurmountable obstacles.

Civil society brought the disease – and the needs of those affected – to the forefront of world attention. Attitudes changed. Treatments were developed. Clinical schedules were streamlined and standardized. Funds were found. Prices dropped. Partnerships were formed, and presidents and prime ministers launched emergency plans.

The response to AIDS also reaffirmed some of the most important values and principles of public health. The AIDS epidemic showed the relevance of equity and universal access in a substantial way. With the advent of antiretroviral therapy, an ability to access medicines and services became equivalent to an ability to survive for many millions of people. The epidemic focused attention on the broad social determinants of health, the vital role of prevention, and the need for people-centred care. In so doing, it helped pave the way for a renewal of primary health care.
These achievements show the power of determination and global solidarity, but they also remind us of the challenges. I believe that the theme selected for this year’s World AIDS Day captures these challenges well.

Leadership is needed to ensure that vigilance and diligence in responding to the epidemic remain steadfast. Despite the global financial crisis, funding absolutely must remain predictable, sustainable, and substantial. We must ensure that the current unprecedented rollout of treatment reaches more people and is fully sustainable. Stepping back or slowing down on treatment is not an acceptable option on ethical and humanitarian grounds.

Empowerment is critical for an effective response, and most especially so for prevention. We must do much more to empower adolescent girls and women, both to protect themselves and to act as agents of change. We must work much harder to fight stigma and discrimination, which are huge obstacles to all forms of prevention, treatment, care, and support. In many countries, legal as well as social and cultural barriers prevent groups at risk from receiving the interventions and knowledge needed to reduce harmful behaviours.

Finally, we must deliver. In many countries, the weakness of health systems limits the ability to reach those in greatest need with sustainable services. I believe we now have an historic opportunity to align the agenda for responding to AIDS with the agenda for strengthening health systems. As noted in this year’s World Health Report, primary health care is the best way to operationalize a commitment to equity and social justice, to realize a focus on prevention, and to reach marginalized groups. These values and principles are the very foundation for the future of the AIDS response.

On this World AIDS Day, let us redouble our determination to build on past success and to rally our forces against the remaining obstacles – in a spirit of solidarity and for the sake of human dignity.

Catholic Social Teaching and Healthcare Reform

In Matthew 25, Jesus paints an image of His return in glory. On the Day of Judgment, Christ will separate His sheep from the goats. The sheep are those that cared for "the least" of Jesus' brothers: the hungry, the thirsty, the naked, the stranger, those sick, and those in prison. The goats didn't remember "the least" among them and as Christ foretold, "in all truth," they have "received their reward," in this life and will not in the next. Jesus’ teaching is unavoidable.

This message is especially relevant to the injustice of the American healthcare system. To call American healthcare—as a system—immoral makes no judgment on healthcare professionals or hospitals, but rather on the design itself. Many have advocated for universal healthcare in our country and have been rejected for proposing so-called "socialized medicine." I am personally a proponent of a universal healthcare system. We have the medical care, the financial resources, but we seem to lack the moral will to acknowledge that we are our brother's keeper.

Does the United States have the best healthcare in the world? It depends. In reality, there are at least five different co-existing healthcare systems in our country. They can be described as follows: first, at the top of the system are the wealthy and well-insured, particularly those with indemnity, fee-for-service health insurance. In this case, the United States has the highest quality, most technically advanced medicine in the world; second from the top is the private, employer-based insurance for the middle class, usually with some features of "managed care" and some restrictions on what the insurance company will cover; the third layer consists of insurance for lower-income workers in the form of tightly managed health maintenance organizations (HMO), substantial out-of-pocket payments and moderate restrictions on the doctors that can be seen and treatments covered; the fourth layer is Medicaid, Medicare, and the State Children's Health Insurance Program (SCHIP), which are grossly underfunded systems of federal and state insurance for the lowest of middleclass families, the poor, for children, the disabled, and the elderly. This group faces severe restrictions on doctors that can be seen and on treatments covered; the bottom of the ladder is "charity care" and emergency room care, which is available to those who have no medical insurance.

The American healthcare "system" translates into a socio-economically based distribution of medical care, which is fundamentally more of a medical caste system than a healthcare system. This hardly seems compatible with Jesus' teaching in Matthew 25. The results aren’t either. In virtually every form of basic statistics measuring days of illness, death rates, and life expectancies, the United States ranks behind almost every other industrialized nation. The U.S. ranked last in 2007 of every industrialized nation in terms of the citizens dying from preventable disease; France ranked first. In France 64 people died from preventable disease, in the U.S. approximately 101,000 died from preventable disease. The difference couldn't be starker, particularly given the fact we spend more on healthcare than any other industrialized nation in the world and for us it is only partial, not universal coverage as in other countries.

The "every-man-for-himself," radical individualist strategy of American healthcare not only is disastrously irresponsible, it seriously violates basic Christian teaching. Make no mistake, this is not an endorsement to eradicate personal responsibility and moral virtue (communism, in other words), but an observation that a private sector dominated healthcare system is bad business without some sort of minimal regulation. The Catholic principle of subsidiarity is an organizing principle that calls us to allow the smallest, most local institution to handle matters if it can be done more efficiently than or just as efficiently as would be done at the national level (or state level in America). But, if the task cannot be done efficiently at this level, then the national (or state) government has an obligation to have some sort of role to ensure the common good.

Any healthcare system—in my view—that is based on private insurance with no government intervention is fatally flawed. The incentive of private insurance is upside down. After premiums are paid, the less care they provide, the higher their profits—this is undoubtedly their goal. Hence, all the horrid stories one hears about insurance companies searching for the smallest technicality to not cover something. Thus, public health and human welfare is not the incentive, but rather profit. Profit over health and dignity is not a Christian value. Fundamentally, health and wellness should not be treated like any other consumer-based industry.

The problem with healthcare costs is hard to deal with in the current system. With thousands of different private health insurance plans, it's virtually impossible to negotiate consistently lower costs with healthcare providers and drug companies. A universal healthcare system, on the other hand, has the potential to rein in costs. More importantly, private insurance is a colossal waste of money. Administrative costs for Medicare, for example, which is government-financed (not government-run) are 2-3% of the total cost. Approximately 30% of private insurance premiums go to overhead, profits, and executive salaries. Overall the administrative costs of private insurance exceed $400 billion dollars in a year. That is arguably sufficient to cover all the uninsured without raising taxes.

Many conservative-leaning thinkers are concerned about the loss of freedom and the efficiency of a national healthcare plan. Ironically, the freedom that many people fear will be loss at the implementation of a universal healthcare system is already gone. Many choices in healthcare are at the discretion of the private sector insurance companies. They choose what doctors you can see, whether you are qualified to be covered (if you have a history of illness, good luck—you cost too much), what they will and will not cover and how long you can receive treatment, and this is all if they don't find some small technicality on which they can drop coverage all together to preserve their profits. It seems that we fail to realize how much is already controlled by large corporations—at least government officials can be voted out of office.

Even more so, we already pay for people to get medical care. When people go to the emergency room to receive medical treatment without health insurance, the cost is spread amongst everyone else. This is one reason why insurance premiums skyrocket and we're also taxed, since hospitals can receive government grants to offset some of their losses. Wouldn't we rather have paid for the preventative care than wait until it is much more expensive?

Additionally, it is nothing unusual for a hospital to have to bill more than 700 different payers and insurers--HMOs, PPOs, MCOs, IPAs, and an alphabet soup of other organizations. Each one has its own set of rules for what services are covered, the level of reimbursement and the kinds of documentation and pre-approval required. It is an administrative nightmare. And for this mess, we Americans shell out $2.2 trillion a year (more than any other nation) and all this inefficiency costs patients tens of billions of dollars each year. Billing, collection, and payment administration represents some 20 percent of that $2.2 trillion we spend on healthcare. There is nothing even remotely "conservative" about this—it’s nothing but “big spending” and for what results?

To consider this again in Christian thinking—we have a call from the Lord to give preferential option to the most vulnerable among us. Poverty and ill health travel often together. Poverty puts one's health in jeopardy, ill health with its attendant high medical bills, impairment of working ability, and days lost from work, make it difficult to find and hold a good job. This is a terrible and vicious cycle. The current healthcare system is evidently not accommodating.

Now there is a "safety net" of charity healthcare that ought to be commended. The Veterans Administration healthcare system, the Indian Health Service, state and local departments of public health, public hospital emergency rooms, community health centers and clinics, faith-based clinics for the poor and homeless, and the list goes on. Despite their tireless work and efforts, many lack the funding and the resources to address the problem at hand—they adequately cannot overcome the effects of the lack of good, regular access to mainstream healthcare.

Hispanics, African Americans, people with less education, part-time workers, and foreign-born persons have the highest rates of being uninsured. Guess what? They also are the same people who have more abortions. 1 in 2 African American pregnancies end in abortion. African American children are born into this world more often than not with the odds against them—the black community is experiencing a terrible crisis of missing fathers, thus single parent households. Statistically, children that grow up in such environments are inclined to have a weak parent-child relationship, prone toward committing crime, drugs, alcohol, sexual promiscuity, more likely to repeat a grade, less likely to graduate high school, and are often victims of abuse and neglect. And single mothers, particularly young ones, face a long, uphill battle toward economic self-sufficiency and the current healthcare system does little to help those in this sort of situation.

The elderly have limited economic productivity and healthcare is getting exponentially more expensive; we have a moral obligation to see that their needs are met, particularly for a group that often has very dire medical needs. While there is Medicare, it faces problems in providing long term care of chronic conditions, incorporating new technology, and lacks the financial resources needed.

Much of this may be slightly more "liberal" than one's own political perspective, but Catholic Social Teaching is beyond "left" and "right" politics. If we subjectively identify with one side of the political spectrum more than the other, we must do so as Catholics, which entails crossing party lines. We cannot continue to allow our politicians to cover unborn children in the children’s healthcare program to encourage women not to have abortions only to denounce expanding coverage, or redirect funding from the program. This isn't all "liberal" either. We need to heed the Bishops advice on the both/and approach. There is another side of this debate that conservatives need to win. That debate is in regard to much of the content of American healthcare and this debate involves religious freedom, Catholic and private hospitals, abortifacents, emergency contraception, patients rights', and the full range of so-called "reproductive health services," in vitro fertilization, genetic manipulation, etc.

The Democratic Party is currently the natural home of legislative proposals for healthcare reform. I firmly believe that universal healthcare is going to come sooner or later and if Catholics aren't sitting at the table, our values will be off the table. I see this fundamentally as a "life issue" in its own respect and from a pro-life perspective, the status quo is not acceptable. We may not agree on the details, but on fundamental principles of human dignity, basic civil rights, and the end goal of, in some way or another, providing universal access to quality and affordable healthcare, there should be agreement. No one should be left out. That’s the ideal goal.

Back to the fundamental question: does America have the greatest healthcare system? Not at all and I don't even think it's debatable. And reform is not only necessary, it is required.

FACE AIDS: A Growing Crisis

Frequently in discourse with non-Catholics, or some Catholics even, when the issue of contraception and the AIDS epidemic arises, there is uneasiness about the Church’s teaching on dealing with this deeply troubling matter. One might argue that by maintaining opposition to the use of condoms, the Catholic Church contributes rather to the spread of AIDS in Africa, for if the “Vatican hierarchy” cared more about people’s lives than rigid doctrines that even most Catholics reject, they would change their view to prevent the spread of AIDS. Why? It is the more “pro-life” thing to do given that it would save millions from dying from unprotected sex.

While the presented argument is well-intentioned, it is also profoundly incorrect. The Catholic Church doesn’t oppose contraception on the basis that it is a “nice rule” that Catholics should follow, but rather contraception is contra-human nature—it is an objective, moral evil that disrupts the purity and creative design of the sexual act. Much can be said on the matter, but what is relevant is that by isolating sexual pleasure from the procreative element built into the sexual act itself, one subconsciously (and consciously) affirms the sinful tendencies of lust, self-gratification, and promiscuity.

Why? If a man can sleep with multiple women (separately or even together) and experience sexual pleasure in abundance without any concern of producing children in doing so, he’ll be inclined to do it—and maybe he’ll become addicted to it (‘it’ being sexual pleasure). The result? Men objectify women, see them as objects and not as equals; men (and women too) have routine, recreational and meaningless sex unconcerned with reproduction because that “problem” has been solved. The consequences of such actions are grave and unfortunate. Not only is such action self-destructive objectively for all persons involved, it is harmful to society. Naturally such behavior leads to single mothers and dire poverty, abortions, the oppression of women, skyrocketing divorce, the growth of other vices, and the spread of sexually transmitted diseases.

To the issue of AIDS — statistics repeatedly show that condoms really have not been very effective in the fight against AIDS despite the fact it has been the principal prevention device for the last twenty years. Billions of condoms have been shipped to Africa in order to deal with the epidemic. The countries that stress condom use are not seeing any great decline in the virus, but rather, the opposite. Luckily, there is a clear example of an African nation turning back the epidemic of AIDS by other means. In the late 1980s Uganda was viewed as the worst nation in the world in terms of HIV/AIDS infections. Currently, instead of placing the primary emphasis on condoms, they emphasized abstinence and faithfulness first. As a result, they have experienced the greatest decline in HIV in the world.

Some might assume, “Well, some protection is better than none.” Of course, this would seem to be a logical argument at first. After all, condom use can reduce the odds of HIV transmission during an act of intercourse. But it still remains that in the presence of an epidemic, unless a person changes his or her behavior, it may be only a matter of time before he or she is infected. When people are not taught the difference and are left thinking that risk reduction equals protection, they are more open to take risks that they cannot afford. Another reason why condoms have failed to stop AIDS is that when a person is infected with other STDs, they are up to five times as likely to get HIV if exposed. There are several reasons why this occurs; one reason is that many STDs cause sores that can serve as portals of entry for the virus. For example, a woman’s reproductive tract is often able to protect her from HIV. However, this natural barrier is compromised when she is infected with certain STDs. Considering that the number one determinant of STD infection is multiple sexual partners, any strategy to stop HIV that does not reduce sexual activity will have limited effect.

Why is abstinence so effective? In abstinence programs, people are encouraged to abstain from sexual activity until marriage and are encouraged to be tested for HIV regularly. The contraceptive approach doesn’t take a fundamental reality into much consideration: the infectivity rate of HIV. The infectivity rate of a disease or virus measures the likelihood of its transmission. For HIV, it is estimated on average, the odds of being infected with HIV through a single act of intercourse (without a condom) is about one in a thousand. However, when a person is first infected with HIV, he or she is highly contagious. But if this person were to get tested for HIV right away, the test would show that he or she is HIV negative, despite the fact that he or she does have the virus and can easily transmit it. Here’s why: Technically, the HIV test does not look for HIV, but for antibodies against the virus. Antibodies are what your body creates to fight off intruders. But viruses are pretty smart and it can take months before your body knows that you have one (and maybe even a decade before you know it). So if your body does not know that you have been infected with HIV, it won’t produce antibodies to attack the virus. So if the HIV test doesn’t find the antibodies, the doctors will tell you that you’re HIV negative. Meanwhile inside the body of a newly infected person, the HIV plasma viral level is very high, especially in the genital fluids (semen and cervical-vaginal fluids), because there aren’t any antibodies around to reduce their levels. Since the viral load is thousands of times higher, and the person is shedding viruses, the infectivity rate soars in the early weeks on infection.

This means that if people abstained from sex or were encouraged to wait until marriage (rather than seeing sex as a recreational activity that you can just “band-aid” with a condom), then the odds of HIV transmission would be reduced dramatically. Within a generation, HIV would no longer exist at its current epidemic levels.

Why is this important? AIDS is a transnational global health phenomenon that isn’t unique to third world countries. The Democratic Party is very concerned about this growing epidemic and often ranks it high in their list of things to do. This is certainly commendable. But, the Democrats endorse a strategy—wanton distribution of condoms—that has proven fatal and ineffective. It perhaps even makes the situation worse. The Republican Party under the leadership of President Bush began to promote abstinence in Africa (which works), but this is not very high on the list of things to do despite the fact that this is an international health crisis that is spreading at an alarming rate. In essence, neither party is giving us much needed headway. Democrats simply wish to throw money and condoms at these people (nothing surprising there); Republicans cut funding and promote abstinence. (nothing surprising there either; I’ll add here, I’m not opposed to budget cutting given domestic problems, if we’re advocating for more international support in place of solely American money).

On a side, but relevant, note, I think it can be agreed upon that the most common view of many American Catholics is that the Republican Party is comprehensively right on family, marriage, and the “life issues,” while the Democratic Party is more in alignment with the Church’s teachings on “social justice.” I can easily see how a person falls into the temptation of this sort of thinking, but I do think it’s profoundly mistaken.

If we were to follow the just-described view, the Democrats are better positioned to combat the global AIDS epidemic—which is regarded as a “life issue” and one issue among many others (healthcare, war, etc.) that Catholics use to support pro-choice Democratic candidates, namely, a collect set of issues they deem Democrats better equipped in to bring about “social justice.”

I personally sympathize with their view. Nevertheless, a well-formed Catholic conscience begs to differ and would see the profoundly flawed thinking in strategy that is far from life-affirming, thus, no social justice at all. We can’t settle for what the media tells us nor the latest novelties or refashioned dishonest rhetoric of liberal-partisan groups like Catholics United. Additionally, the fact that the Democratic Party is profoundly wrong in strategy doesn’t lead us to just settle with current Republican efforts—much more can be done.

This can’t be a small matter for Catholics. Every 11 seconds someone dies from AIDS. We can’t call ourselves morally coherent and pro-life if we stand by idly as this horrendous cancer fueled by sin kills our brothers and sisters. Are we not our brother’s keeper?

Pray for those with AIDS.