Preaching Prevention. Lydia Boyd

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СКАЧАТЬ a nearly fivefold increase.³⁵ PEPFAR has dramatically expanded funding for both treatment and prevention in Uganda; for fiscal year 2008, the program accounted for $283 million of the $388 million in Uganda’s budget for AIDS prevention and treatment and provided more than 70 percent of the country’s entire resources for HIV/AIDS treatment and prevention, far outpacing the contributions of the Ugandan government and the UN Global Fund, Uganda’s second biggest contributor to HIV/AIDS programs.³⁶ By all accounts PEPFAR is a program that has redefined HIV/AIDS treatment and care worldwide.

      Despite these transformational numbers, PEPFAR was not wholeheartedly embraced by the global AIDS care community. As was noted in this book’s introduction, the most controversial aspect of PEPFAR was that the program reserved one-third of its prevention funding ($1 billion) for abstinence and faithfulness-only programs.³⁷ At the 2004 International AIDS Conference in Bangkok the structure of PEPFAR’s prevention funding drew intense criticism. An editorial in the Lancet described the tense reception at the conference of President Bush’s Global AIDS coordinator, Randall Tobias: “Tobias was distinctly ill at ease and, for a few moments as he left the podium under strong verbal attack, it appeared that he would withdraw from the lecture.”³⁸ Criticism extended from questions about the president’s motives and especially the clear focus that Bush and the program’s terms had placed on the role of religion in the fight against AIDS.³⁹ The Lancet editorial recounts Bush’s speech, in which he touted an ABC approach (abstain, be faithful, and—adding the qualification “when appropriate”—use condoms) as a “moral message” and placed special emphasis on the importance of youth abstinence as an approach that prevents HIV “every time.”⁴⁰ Many in the world of AIDS prevention distrusted the focus on abstinence, especially as it sought to drive funding away from other programs (in particular, those of condom distribution) that were perceived as less aligned with the Bush administration’s social agenda.⁴¹

      A Ugandan Christian activist I knew recalled for me his experience at the 2004 Bangkok conference, where he participated in a panel that seemed to dramatize the tensions of the moment. He was only in his early twenties at the time, and this trip—which took him halfway around the world—was the first time he had ever been on an airplane or traveled outside eastern Africa. At the time he was, he admits, unfamiliar with the landscape of international AIDS activism; his experience with AIDS advocacy extended only to his role as youth leader at University Hill Church (UHC), a congregation near Makerere University in Kampala that advocated premarital sexual abstinence. He had been selected as a youth representative for Uganda at the conference and was slated to appear on a panel discussing the role of abstinence programs in HIV prevention. He described to me his initial realization that controversy surrounded HIV prevention methods, especially abstinence:

      At that point I wish I knew better. I was in my final year at the university. It was an international AIDS conference. I was in Bangkok, in Thailand. It was my first opportunity to fly. It was really great. One of the greatest things, as a leader, is your story of transformation. So I had my story, you know. This is what had happened, this is what changed . . . ​I made the decision to abstain, and I’m just living my life and going on. And so I go over and I was simply supposed to give my testimony. And some guys were like, “Abstinence is an illusion, it doesn’t happen.” The guy who spoke before me, Dr. Steven Sinding [who represented] Planned Parenthood,⁴² and then a girl from India. And I was like, “Guys, am I an illusion? I made a decision to wait! And I’ve been waiting, and it helped me!” So this was really eye-opening for me. There were four people presenting, but 80 percent of the questions came to me. But I kept the story. Some guys came and said, “Thank you very much for sharing the story.” Then I talked to [prominent American evangelical minister] Rick Warren’s son, shared with him some personal things, kept him in prayer, and then we kind of kept in touch.

      Andrew had been prepared to “testify” in a mode of speaking common to evangelical and born-again Christians the world over. Testimonies are narratives of personal transformation shepherded by faith. In Andrew’s eyes his faith had helped him abstain from sex, which had enabled his transformation from a sinful youth to a principled young man. For him this was a positive story, one laced with allusions to his own aspirations and personal achievements: nearing completion of his college degree and planning for marriage. This was a message central to the teachings in Andrew’s church—that abstinence could be a strategy of upward mobility and social achievement—and it was one now being sanctioned by the U.S. government. Andrew and his peers’ experience with abstinence is a topic I will return to at length in later chapters, but the story he tells here is about the controversy that surrounded abstinence, and the sense of division within the world of AIDS activism that PEPFAR had seemed to generate. Andrew had been dropped into a struggle over public health policy that was animated by a broader conflict rooted in the U.S. religious and political landscape. In Bangkok, the first major international AIDS conference following PEPFAR’s introduction, an American conservative coalition had, to an uncertain reception, thrust itself into the world of AIDS research and programming. Andrew’s offhand mention of Rick Warren highlights the way in which PEPFAR and abstinence had emerged as a key arena for this American struggle, and the ways in which American politics and American religion had come to have an impact in even seemingly remote African communities. In fact, these African communities were placed at the very center of these debates.

       Harnessing the Story of Uganda’s Success: Defining Behavior Change

      It was also at the Bangkok conference that the Ugandan story of declining HIV prevalence rates took center stage, in large part because the Bush administration had cited the country as evidence for why abstinence and faithfulness-only programs had been earmarked for special funding. Ugandan president Yoweri Museveni was a featured speaker at the conference, and he delivered a wholesale celebration of individual responsibility and self-control as frontline defenses against the epidemic:

      Eighteen years ago, as we emerged from a two decades protracted peoples’ war of liberation against the dictatorial regimes of [Idi] Amin and [Milton] Obote, Uganda was once again under the shroud of a devastating mysterious ailment called “Slim,” later to be known as AIDS. Two decades of civil war, state mismanagement and inappropriate monetary policies had left the Ugandan economy and social infrastructure in tatters with extreme levels of household poverty. The medical infrastructure, especially the hospitals, were in a sorry state with many of the medical profession living in exile, and the total per capita expenditure on health at less than $1 per annum. By 1985, Uganda was among the ten poorest countries in the world.

      We had to transmit to our people the conviction that behavior change and therefore control of the epidemic was an individual responsibility and a patriotic duty and within their individual means. In our fighting corner was a resilient population and a committed leadership with years of fire-tested experience in mobilizing our people to overcome obstacles at great odds and with minimal resources.

      Our only weapon at the time [was] the message: “Abstain from sex or delay having sex if you are young and not married, Be faithful to your sexual partner (zero grazing), after testing, or use a Condom properly and consistently if you are going to move around. This has now been globally popularized as the ABC strategy.” With no medical vaccine in sight, behavioral change had to be our social vaccine and this was within our modest means.⁴³

      By the late 1990s, HIV/AIDS had become increasingly important to Museveni’s profile on the international scene, bolstering his image as a “new African statesman” intent on supporting political reforms and terms for economic growth that were supported by his allies in the West. Uganda’s government, like others across Africa, had become heavily dependent on foreign donor aid during the 1980s and 1990s; by necessity Museveni had embraced economic restructuring in 1987, opening Uganda to international donors who had avoided the country under the Amin dictatorship of the 1970s, a period that had been characterized by intense xenophobia and economic isolation in Uganda. While Museveni had come to power in the mid-1980s as a leader espousing “revolutionary” politics with an antielitist and broadly socialist СКАЧАТЬ