The AIDS pandemic challenges many religious beliefs about health (and vice versa). It has changed the ways many public health and development specialists see religious leaders and institutions and their health roles; the complex experience of religious institutions working on AIDS inspired the Lancet to devote an entire issue to the role of religion in public health. Fundamental ethical issues about human rights and human dignity emerge in stark terms, touching families and global institutions. The pandemic has forced and continues to force us to think and reassess as facts and experience jolt stubborn assumptions. Amidst unspeakable tragedies -- AIDS has already claimed 34 million lives - we can catch glimmers of hope in this journey of change.
The 34-year history of AIDS as a known disease offers a parable about intersections between faith and behavior, admonition and care, and ideals in the face of realities. It highlights in immensely practical ways how religion and public health policy are intertwined.
The turbulent history of HIV and AIDS is packed into a single generation.When my daughter (now a young physician) was born in 1980, HIV and AIDS was unknown. I was working in Africa then and AIDS was nowhere on any development agenda. Today it is a central medical and development issue; HIV and AIDS expenditures are over $20 billion, and accounted for some 24 percent of global aid spending for public health in 2012. Affecting different countries and communities very differently, it has unfolded as a global disease, challenging institutions from the United Nations to local governments and communities. It puts the world's vast health care disparities, unequal and discriminatory gender relations, weak management of public health programs, and unsustainable patterns of international development finance into stark relief.
So where does religion come in? Such questions evoke two dramatically different responses, simultaneously. A positive narrative casts religious actors as the face of care and compassion, witnessing what is truly happening in communities, challenging apathy, demanding action, and speaking truth to power. Devoted caregivers offer tenderness and practical health care. They call attention to the orphans left behind and take them in. They cradle abandoned children born with AIDS as they die. The second narrative sees religious leaders and communities as denying the very reality of the disease, condemning those affected by HIV and AIDS, to the point of refusing burial in churchyards, fostering stigma and discrimination against groups poorly placed to offer any defense, poisoning debates about vulnerable groups, blocking proposals for sex education, and generally bolstering the tendency to denial.
This rough dichotomy obscures a far more complex picture. The situation varies widely by country and community and above all it has changed. Responses by the complex maze of religious institutions and individuals - Catholic priests, Catholic nuns, Buddhist monks and nuns, Muslim imams, Pentecostal pastors, and Hindu spiritual leaders - differ and vary over time and within communities.
As understandings about the pandemic increased, encouraged by leadership from above and the lived realities of believers and leaders at the community level, so have constructive religious responses. As faith-run medical facilities were overwhelmed by patients with AIDS, their managers demanded action and support. As pastors and monks (as well as teachers and army officers) died of AIDS, communities were jolted into understanding. Leaders spoke out and denominations mobilized to respond and to demand global action. Bold HIV and AIDS education programs were launched. Orphan care increased. Community programs emerged to support entire regions where the pandemic raged. A national alliance including Muslim and Christian leaders helped stave off AIDS in Senegal.
There are many inspirational examples of leadership. Ugandan Canon Gideon Byamugisha spoke publicly when he learned he was HIV positive, with his bishop's blessing. Archbishop Desmond Tutu and Archbishop of Canterbury George Carey galvanized the Anglican Communion to make fighting AIDS its priority. The lay Catholic Community of Sant'Egidio developed a state-of-the-art AIDS program in Mozambique predicated on the principle that quality of care must be as high in Africa as in Italy. Kay Warren read in a beauty parlor the figure of 16 million AIDS orphans and she and her husband, American megapastor Rick Warren, have campaigned ever since to make AIDS a leading priority. Father D'Agostino, the Jesuit priest who created the Nyumbani orphanage in Nairobi to care for abandoned babies with AIDS, caught my attention when he railed at the World Bank for failing to finance ARVs on grant terms. Dr. Hany El Banna led Islamic Relief in a global conference in South Africa where no topic was taboo and new pacts were forged. Bishop Gunnar Stalsett from Oslo co-chaired the 2006 Toronto AIDS Summit. South African Catholic Bishop Kevin Dowling has spoken forthrightly supporting condom use to prevent HIV transmission. Monks in Thailand and Cambodia are at the forefront supporting those living with HIV. An example of efforts to engage faith leaders more actively was the March 2010 global summit of religious leaders on HIV in the Netherlands, where religious and spiritual leaders from major world religions pledged "stronger, more visible and practical leadership in the response to HIV".
Individual and global advocacy has inspired and goaded global leaders to increase sharply their support for HIV and to create bold new programs and institutions. The most striking example was the central and well documented role that faith actors, many from conservative traditions, played in persuading US President George W. Bush and a skeptical US Congress to launch PEPFAR (The President's Emergency Program for AIDS Relief) in 2003. The direct lobbying efforts of religious leaders and their appeal to a morality of compassion and equity harking to core religious values changed hearts.
In global debates about HIV and AIDS some "elephant" issues still generate tension and controversy. Many AIDS advocates challenge negative influences of religious groups and religious ideology on public policy. This plays out in how funding for HIV responses has been directed and in the policy making arena around HIV, sexual and reproductive health, and gender both at the UN and national levels. Directives to concentrate US funding on "abstinence only" programs and application of the so-called 'gag rule' had negative effects on the HIV epidemic and public policy and still obstruct rights based approaches to public health. A second "elephant" is the role that some religious leaders play in fostering or failing to combat the stigma and discrimination that is so important to perpetuating the pandemic. Knowledge about the causes and transmission routes are vital and depend on education and sharing of information, but many religious actors still object to such programs. To degrees that are difficult to measure, religious attitudes affect political and social approaches to vulnerable groups: notably men who have sex with men (MSM), intravenous drug users, sex workers, and adolescent girls.
The HIV journey is an often-inspiring story about interactions between faith and non-faith actors and the nature and dynamics of mutual learning. These are vitally important for HIV and AIDS, but also for other health challenges, including Ebola, tuberculosis, and family planning. Lessons from best and worst practice, highlight the key strengths and weaknesses of faith leaders and communities in global health. Broad issues lurking beneath the surface of development debates have emerged, some confronted, others still on the agenda. These include how faith actors deal with gender inequalities, for example ancient patterns of accepting gender-based violence, and reticence or unrealistic teachings about sexual and reproductive health. Lively conversations about stigmatization, acceptance of discrimination and intergroup violence, and harmful use of religious rhetoric help build common ground and do bring change and better understanding. There are many examples of wisdom and courage in confronting all these areas, and inspirational examples of changed positions in the face of evidence. However, not all the battles are behind us and confrontations leave scars. Religious advocacy for legislation to criminalize HIV transmission and homosexuality in some countries is a stark example of an issue that has not been laid to rest.
On this World AIDS Day (December 1, 2015) the messages are hopeful. The end is in sight. But there is still a long research and policy agenda and millions who suffer. So it is vital to hammer home many vital lessons, among them the benefits of involving people living with HIV and communities, looking to creative partnerships with faith actors, and focusing more sharply on the complex dynamics of behavior change.