海角大神

In the center of Kayesa, a sun-drenched village in central Malawi, stands the empty shell of a public health clinic.

Its red brick walls are gap-toothed and end abruptly at window height, where construction stopped when the village chief ran out of money last year. Goats wander lazily through the half-completed structure, picking at fruit peels on the dirt floor.

But only about 100 yards away, villagers wait听patiently听in a long line to visit with a doctor at Kayesa鈥檚听Catholic听church, St. Mary鈥檚. Inside the squat one-room brick building, a team of Slovenian doctors and medical students who visit the village twice a month briskly dole out antibiotics, wound dressings, and advice on HIV treatment. Boxes of their supplies lie sprawled across the altar.听

Across much of sub-Saharan Africa, this is a familiar scene. In a region that is home to both many of the world鈥檚 poorest states and its sickest, countries have long turned to private healthcare providers 鈥� many of them faith-based 鈥� to fill the gaps in their coverage. Indeed, five decades after Malawi's independence, churches are still responsible for 40 percent of all healthcare provision in this sliver of southeastern Africa, and 80 percent in so-called 鈥渉ard to staff鈥� areas, according to the US State Department.

The impact has been particularly notable in confronting HIV/AIDS听as it swept across the continent over the past three decades, particularly in those remote areas where governments are hard-pressed to provide services.听Today, the Vatican and UNAIDS estimate that the Catholic听Church 鈥斕齱hich mounted an early and听massive ground-level response,听building up a network of听hospitals, hospices, orphanages, and clinics 鈥� administers 25 percent of all AIDS treatment, care, and support throughout the world.听But听like many other faith-based groups听here,听Catholic听health workers say their primary motive is helping support essential healthcare provision, rather than promoting conversion.

鈥淲e often say that we serve people because we are听Catholic, not so that they will be Catholic,鈥� says听Father Bob Vitillo, the special adviser on HIV/AIDS for Caritas Internationalis, the global federation of听Catholic听charities. 鈥淭here is no proselytizing to the sick.鈥�

But the institution鈥檚 future in the fight against HIV/AIDS is increasingly uncertain.

Many听governments 鈥� including Malawi鈥檚 鈥� are听working to gradually reduce their reliance on private providers听such as churches.听Global funding for faith-based AIDS relief听is also听shrinking. That, many argue, is a good thing 鈥� a pivot toward self-sufficiency for countries historically reliant on missionary handouts for the provision of even basic social services. But the institutional roots of the church remain far deeper than the roots of government across much of Africa, and its reach more expansive, underscoring for many observers the need to recognize churches' ongoing importance amid efforts to improve health care on the continent.听

鈥淚n many countries, delivery of health care has naturally become a social good expected of the state, and so it听remains then to think out what the future role of听church medical institutions should be,鈥� says Ken Johnson, a lecturer at the Malawi College of Medicine. "It is a mistake for听Catholic听hospitals to insist on doing basic services ... rightly taken up by government. But rather let them be creative, because there remain many unmet health issues."听

Positive sign: a business declines

For Harrison Chiringa, a coffin-maker in the Malawian city of Kasungu, which lies 65 kilometers (about 40 miles) from Kayesa by bone-rattling dirt road, the impact of church healthcare in the region isn鈥檛 hard to isolate 鈥� after all, it鈥檚 had direct bearing on his business.

鈥淲hen I opened my coffin shop in 2008, I could sell two, sometimes three coffins a week,鈥� he says. 听

In the small workshop behind the store, he and his assistants were perpetually busy transforming slabs of raw wood into the glossy handled boxes now on display.听 The most ornate sold for as much as $150, a princely sum in a country where 40 percent of the population lives on less than $1 per day.

But today, Mr. Chiringa says, he sells听perhaps two per month, and the rows of coffins at his feet are literally gathering dust in the whitewashed shop.

It is a marker, in part, of a broader transition this part of the world has undergone in recent years, as improving HIV/AIDS care meant the disease was no longer so certain and prevalent a killer.

In Malawi, life expectancy climbed from 40 years in 2000 to 55 in 2011. And even as the prevalence of HIV fell from 14 percent to 11 percent听during the same period, locals say the number of people living openly with the virus rose steeply.

Part of the responsibility for the pivot belongs to the government, which runs a large hospital in Kasungu and, since 2004, has dispensed free antiretroviral treatment 鈥� ARTs 鈥� to any sick Malawian who can reach one of its HIV clinics.

But for many here, that鈥檚 a near impossible challenge.听Less than half of Malawians are within a five-kilometer (3-mile)听. Nearly every village, on the other hand, has a Catholic听church.

听鈥淕overnment just doesn鈥檛 have the capacity to treat everyone, especially in the rural areas,鈥� says Henry Lunda, who for several years ran the听Catholic听Church鈥檚 AIDS relief program in the region around Kayesa.听鈥淭hey rely on the church programs. I don鈥檛 know if they want to, but they have to.鈥�

'We are very far away from Rome'

For the听Catholics, AIDS ministry here began as it did in most places across Africa 鈥� by providing hospice care.

Through the 1990s and into the early 2000s, 鈥渢here was little we could do except help people die with dignity 鈥� and then provide support to those who were left behind,鈥� says Father Vitillo of Caritas Internationalis.

But by the mid-2000s, the landscape began to shift. AIDS was becoming a chronic but treatable illness in the West, and a massive influx of donor dollars 鈥� led by former President George W. Bush鈥檚 President鈥檚 Emergency Plan for AIDS Relief (PEPFAR) 鈥� promised for the first time to bring the new medical treatment to the heart of the epidemic: sub-Saharan Africa.

鈥淭he听Catholic听Church was an obvious choice for [international donors] to partner with, because it was already there, already integrated into local communities, and therefore trusted by local communities,鈥� Father Vitillo says. 鈥淲e made a good and simple pitch: It鈥檚 cost effective to work with us.鈥�

There was also another factor that made the听church attractive to Mr. Bush鈥檚 PEPFAR program in particular 鈥� its all-out commitment to sexual abstinence.

In 2008, local Jesuit priests hired Mr. Lunda to take on the church鈥檚 relief program in the Kasungu region. Using European donor funds, they bought a new Land Rover and staffed Lunda with a local nurse and nutritionist. Every day, the team jolted down narrow dirt roads to the region鈥檚 most far-flung villages, where they visited patients, ran support groups, doled out food aid from local听Catholic听parishes, and made house-calls to the very sickest.听

Often, Lunda says, the听church found that local relief programs were already in progress, and simply chipped in funds to keep them going. Just outside Kayesa, for instance, a small, steely-eyed woman named Faucita Banda has, since 2004, been running a cooperative farm staffed by HIV-positive women and AIDS orphans, who shared a cluster of huts at its fringes. Lunda began bringing the women seeds, and helped to drill them a well.

鈥淭his is not about teaching people to become听Catholics. The act of doing good, that鈥檚 how we let people know what our church is about,鈥� he says.

The work has tested the听church in central ways, particularly its opposition to the use of condoms, one of the most championed public health methods for reducing the transmission of HIV. 听

鈥淗ere in Malawi, because of AIDS, we know we must talk of condoms 鈥� there is no running from that,鈥� says Lunda, the AIDS relief worker in Kasungu. 鈥淲hen we have healthy 海角大神s, our churches are full. When they are sick, they do not come.鈥�

For听Anthony Egan,听a theologian with the Jesuit Institute of South Africa, the issue is dealing with the immediate conditions on the ground.听

鈥淭he听truth is, we are very far away from Rome,鈥� he says. 鈥淚n the pastoral experience of most priests and bishops in Africa, what you quickly come to realize is that all the pious theology in the world simply can鈥檛 make moral sense in the face of real and deep human suffering.鈥�

Indeed, in听November 2010, then-Pope Benedict XVI declared that under certain circumstances, condom use was permissible 鈥� appearing to walk back the Vatican鈥檚 1968 degree that all artificial contraception was 鈥渋nherently evil.鈥�

听"AIDS cannot be solved only by the distribution of condoms,鈥� Father Federico Lombardi, the pope鈥檚 spokesman, quickly explained. "At the same time, the pope 鈥� believes that the use of condoms to reduce the risk of infection is a 'first step on the road to a more human sexuality,' rather than not to use it and risking the lives of others.鈥�

Ms. Simpwalo's advice

On a recent afternoon in the main examination room of the HIV clinic she manages at Nazareth House, a sprawling orphanage and hospice in the center of Johannesburg, South Africa, Sylvia Simpwalo repeats the counsel she gives daily to her clients.

鈥淚f you are married and your partner has HIV and you do not, then you must use a condom. There is no other choice,鈥� she says.

Ms. Simpwalo鈥檚 clinic sits in the center of a sunny courtyard, flanked on either side by an AIDS orphanage and a hospice. Every day, she says, is a reminder of the way the entire course of a person鈥檚 life can be turned on its head by one careless decision.

But condoms still present her with a moral challenge.

鈥淪ometimes when people use condoms, they feel too free, like they can have sex with anyone,鈥� she says. 鈥淪o we still must teach people the right way to use them, the right situations.鈥�

But a far bigger issue, she says, is the question of how not to lose the progress that this and other听Catholic听AIDS charities have made over decades. 听

Until 2012, Simpwalo recalls brightly, her clinic saw 3,500 patients each month. That year, however, their PEPFAR funding was slashed, part of a wider move by the United States to shift responsibility for AIDS treatment fully into the hands of South Africa鈥檚 government. The country now funds more than 80 percent of its own HIV relief work, threatening the future of faith-based institutions like the Nazareth House clinic. Simpwalo says her facility听听鈥� whose walls are plastered with signs reading 鈥渨elcome to the clinic of hope and love鈥� 鈥� now has just 300 regular clients.

鈥淚鈥檓 worried for the care they鈥檙e receiving at government hospitals,鈥� she says of her former patients. 鈥淪ome of them have a good quality of care, but some do not.鈥�

She is also concerned about something less tangible: a sense of connection between the health of the body and the health of the spirit, and the prudence of treating both together.听

鈥淭he question for us [the church] has always been, how do you help these people [infected with HIV] live a human life?鈥� says Stuart Bate, the former grand chancellor at St. Joseph鈥檚 Theological Institute in South Africa. 鈥淚t鈥檚 not a question simply of blood going 鈥榬ound in your body. It鈥檚 a question of the humanity and dignity of the life you live.鈥�

This story was reported with support from the Ford Foundation.