Race Against Time: Why the Church is the answer
By Robb Sheneberger, M.D.

In this article written for the 2006 Global Summit on AIDS and the Church, Robb Sheneberger examines the global medical approach to the AIDS pandemic and gives practical ways that the Church can address AIDS. Sheneberger is an assistant professor and senior medical technical advisor for the Southern Africa University of Maryland Institute of Human Virology, Zambian Cell.

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“Where is the Church in the global response to AIDS? The Church is everywhere and nowhere at the same time. While the world has identified and attended to the person bleeding by the side of road, much of the Church has largely watched from the sidelines or walked on by. While the world grappled with cost of care, lack of infrastructure, and logistics as limiting beliefs, parts of the Church were stuck in judgments, stigma, discrimination, and apathy as the hallmarks of helplessness.” Robb Sheneberger, M.D.

While it is true that I am a doctor, a scientist, and live and provide HIV care services in Africa, what I want to share with you is not going to be very technical or medical in nature. The title of this conference, ‘Race Against Time,’ has intrigued me because it coincides with many thoughts I have had recently when looking at the global response to the AIDS pandemic. So I want to share some thoughts on the global medical approach to the pandemic, and then focus in on the Church’s response.

Medically, AIDS and the global response has become very much of an emergency. This is easily demonstrated by the World Health Organization’s 3x5 challenge to enroll 3 million people on anti-retroviral therapy by the year 2005, the President’s Emergency Plan for AIDS Relief or PEPFAR, the Global Fund and World Bank’s provision of financial resources, the commitment of the G8 Summit, the philanthropic works of people like Bill Gates, Bono, Oprah Winfrey, Warren Buffett, and many, many others. The contributions amassed have been unparallel in demonstrating a global effort to confront a pandemic that wreaks havoc worldwide.

This emergency had several emergent components to it. First and foremost people, real live, created in the image of God, valuable people were dying in unthinkable numbers on a daily basis. Secondly, it was an emergency that we reverse the popular thinking that it could not be done in sub-Sahara Africa and many other resource-limited areas. Many medical professionals, politicians, economists, as well as, seasoned veterans working in resource-limited areas all claimed the underlying infrastructure and global willpower was lacking to ever address the complexities of AIDS with real, life-saving medical therapies.

Then somehow things shifted. Somehow the wisdom of conducting the 2000 International AIDS Conference in Durban, South Africa, shook the world to a place where the words “no,” “impossible,” and “can’t” were no longer acceptable. The reality of a conference center attached to a luxurious Hilton Hotel in the midst of country still in the infancy of apartheid recovery and faced with continued inequities, and now overwhelmed with the ravaging death of AIDS just outside in the streets was just too great a contrast to each participant to make any excuse sound plausible. The emergency became more real and the response more tangible.

“Only the Church, and by that I mean people sold out to the ministry of Jesus, can create the kind of impact to turn around the AIDS pandemic.” Robb Sheneberger, M.D.

There has been raging debate on the best way to provide medical care in a complex, dynamic disease like HIV in the middle of an out of control pandemic that was costing life every second. I have come to look at the AIDS pandemic like a human lying by the side of the road rapidly bleeding to death. Our immediate response had to be to stop the bleeding. The emergency response focused on a public health approach that aimed to get the maximum number of people on life-saving anti-retroviral therapy in the shortest possible time. The time couldn’t be expended to consider the possible longer-term consequences of our decisions because if we didn’t do something immediately the person was going to bleed to death.

So, although the WHO and others initially made statements to not provide a lesser standard of care in Africa and other resource-limited settings than in the West, the global strategy has been to use the cheapest medical therapies with evidence of effectiveness and distribute them as quickly as possible. It has been the mantra of the Clinton Foundation to drive down the cost of care so that the most people possible could benefit from these interventions. It has indeed made life-saving anti-retroviral therapies available at a scale that many felt was impossible, and broken down many of the walls erected by the naysayer.

When is the bleeding patient, representing the medical emergency of AIDS, stable enough to consider interventions designed to sustain full recovery and prevent the patient from ever re-bleeding again? The therapeutic strategies adopted on a wide scale basis are similar to tourniquets placed to save life, but they are not sustainable solutions for recovering a now more stable condition. The affordable anti-retroviral therapy solution for the mass emergency is not appropriate for long-term healing. This therapy has been replaced almost entirely in resource-rich settings of Europe and the United States by less toxic and more effective alternatives.

These newer anti-retroviral therapies address the primary limitations of current treatment offered to most Africans; those being increasing irreversible toxicity over time and the restriction of therapeutic options once the drugs fail the patient. If we continue on the current course, the risk of impaling Africans with toxicities that compromise quality of life and reproducing a new epidemic of resistant HIV virus is very real. So the challenge medically in resource-limited settings is to devise a strategy to transition from stabilizing a rapidly hemorrhaging patient to supporting full recovery, life, and possibilities.

The infrastructure and systems are coming into place, the financial resources can be made available, but the will to perceive and commit to the bigger vision is in its infancy. A new-phase approach to AIDS care and treatment needs to be initiated. The movement has slowly begun with the WHO 2006 guidelines now recommending the newer alternative anti-retroviral therapies as an option for first-line treatment of HIV, and expanding access to patients less near to death. But the roadmap for sustainable recovery is not well broadcast on an international scale.

It is becoming imperative that the popular public voices imploring the masses with resources to support the end of AIDS clearly understand a long-term vision for success. Now is the time for the medical HIV experts, economist, politicians, celebrities, the Church, and any other involved parties to come together and develop the blueprint for getting the person who was bleeding by the side of the road back on his or her feet again.

I imagine that for any AIDS intervention to really make a significant impact in reducing the number of new infections in the world it is going to need to be applied at the 80-90 percent level. How long will it take to get 80-90 percent of all HIV-infected people on anti-retroviral therapy? This is not even considered an achievable or necessarily a desired goal anywhere in the world, but for anti-retroviral treatment to impact new infections this is the effort required. In the resource-rich setting, most pregnant HIV-positive women are placed on anti-retroviral therapy during pregnancy, and it has nearly eliminated transmission from mother to child. Contrast in Zambia, where I live, it is estimated only 4 percent of women access any form of anti-retroviral therapy during either pregnancy or labor and delivery. So we are a long ways away and do not have the right drugs developed yet to significantly reduce infections through ARV therapy alone.

“The Church can do this, and we are the Church. We can give, we can learn, we can speak out, we can pray, we can go, and we can even stay.” Robb Sheneberger, M.D.

How long will it take to get 80-90 percent of people committed to prevention through strategies like the ABC approach of abstinence, being faithful, and condoms? Studies have demonstrated that less than 100 percent condom use has little impact on transmission rates, and behavioral changes have been difficult in most cultures to sustain over time. How long will it be before a preventive vaccine is available and distributed to 80-90 percent of the people at risk for HIV worldwide? Vaccine research has been ongoing, but to date has not been able to deliver the answers we all anticipated by now and is challenged by a virus that is changing faster than our science. While all of these interventions play an important part and need to be promoted, none either separately or combined will bring an end to AIDS anytime soon.

In the United States, where we have more drugs, more preventive education, and more research than almost anywhere else in the world, there has been a stalemate on the number of new infections for almost a decade. We haven’t even reached an equilibrium point yet in sub-Sahara Africa, and when we do, it will still likely represent over a million new infections a year. The multiple associated costs in caring for even a million new infections each year is daunting. Where is the Church in the global response to AIDS? The Church is everywhere and nowhere at the same time. While the world has identified and attended to the person bleeding by the side of road, much of the Church has largely watched from the sidelines or walked on by. While the world grappled with cost of care, lack of infrastructure, and logistics as limiting beliefs, parts of the Church were stuck in judgments, stigma, discrimination, and apathy as the hallmarks of helplessness.

How long might it take to get 80-90 percent of churches understanding and implementing a vision for being a force for change in their communities? In Africa, I think this is an achievable goal in a much shorter period of time than any other intervention mentioned. The Church is everywhere in Africa. In Africa, when you drive to the most remote location on the worst road imaginable and find people you will find a church. Only the Church, and by that I mean people sold out to the ministry of Jesus, can create the kind of impact to turn around the AIDS pandemic. While the person bleeding by the side of the road is looking beyond the emergency of death to the possibility of life medically, they are still critically ignored spiritually. I would say, though, probably to a greater extent in America than in Africa.

We have much to learn from the rural African’s church sense of community. This conference has to become an encouragement to the greater Church. It is focused on laying aside differences and calling us who claim the name of Christ together to move from helplessness to healers. I believe in Saddleback’s P.E.A.C.E. Plan because I believe in the power of God to change individual lives, then families, then communities, then nations, and then the world. I am encouraged by the decision of some churches to assume responsibility for its past reluctance and speak out about the opportunity to tangibly demonstrate God’s love to the world of persons living with HIV.

In Africa, at almost every meeting I attend that is focused on the obstacles to HIV care and treatment the same limiting factor is mentioned: the lack of human resources. The Church can be the answer to the greatest limiting factor to sustainable expansion of care and treatment for HIV. The Church is chock-full of human resources. Human resources that can be equipped to be instruments for changing their communities and bringing the enemy of AIDS out of the closet and into the open where it can be completely crushed. The possibilities of one community of believers teaching another community of believers so they can teach another community of believers is real, achievable, and greatest opportunity the world has to producing a lasting hope for the end of AIDS.

How did Jesus minister? I see him addressing the felt needs of people who were suffering and dying. I also see him challenging the religious dogma of isolationism and judgment in his day. When the religious church establishment of his day stood over the people with decrees of unrighteousness and removed themselves from the sick and needy, Jesus stepped in and embraced those same rejected people with real grace, forgiveness, compassion, and healing. Even in Africa where the local churches have often become sources of support, there is an undercurrent of stigma, fear, and secrecy that inhibits open engagement and renewal. There is a necessary lying down of religious pride and putting on of humility that promotes healing.

Jesus generally brought healing one person at a time. Medically, our approach to HIV care and treatment has largely been a top-down approach that starts with big governments and programs, and then gradually becomes more decentralized. This approach will not work for the Church, because God is all about relationships. Bottom-up ministry happens through relationship; one church to another, one small group to another, one person to another. It starts one community at a time. It demands a more personal cost, but it is the model of change through relationship we have been given.

Many have verbalized that AIDS is possibly both the greatest health tragedy of our time and the greatest opportunity for the Church to lay down its differences and agendas and demonstrate the love of Christ to the world. I am reminded of Jesus’ words to his disciples, “In the same way I have loved you, love one another,” “love your neighbor as yourself,” “it is more blessed to give than receive,” and “the works that I do, you will do greater works than these.” Jesus kind of sums it up when he says, “Whoever loses his life for My sake will find it.” His sake or purpose was promoting life.

Giving up our life in the midst of American culture and norms is not a popular concept, but what is your destiny, or as Rick Warren would probably say what is your purpose? What are you counting your days for? Where are you accumulating treasures and why? Passion means sacrifice. Jesus was passionate about people and seeing healing and wholeness come to their lives. It cost him, but it is said, “He humbled himself, and became obedient to the point of death.” So as individual followers of Christ we have to count the cost of our call and make a decision to respond.

My vision, my dream, is to see the Church really get it. To see a small African village, impacted by a collection of believers, drag AIDS out in the middle of their village and stomp on its ugly head until it is dead. This includes promoting HIV testing, promoting ARV treatment, promoting adherence, promoting prevention, and caring deeply for those who have suffered loss. The Church can do all this, and we are the Church. Then while in the midst of their victory, they share with their neighboring village the pathway to healing. And so on, and so on, until change is spreading like wildfire. The Church can do this, and we are the Church. We can give, we can learn, we can speak out, we can pray, we can go, and we can even stay. The Church has the opportunity, the example, and the mandate to rise up and be doers of the Word. For the Church, AIDS truly remains an emergency and it is still a ‘race against time.’