Preaching Prevention. Lydia Boyd

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СКАЧАТЬ epidemic. Women also claimed authority from their positions as caregivers and mothers that bolstered their attempts at organizing to prevent the spread of the disease. Museveni, as the country’s most prominent political leader, would particularly be expected to chastise his population into behaving better. But PEPFAR’s funding stipulations asserted a moral discourse that was not rooted in Ugandan notions of proper gender and generational relations or ideas about political patronage and obligation. The rising influence of an American moral discourse rooted in a U.S. Christian conservativism reoriented Ugandan struggles from local relationships to global ones.

       Accountable Subjects: A Policy in Action

      With the implementation of PEPFAR in Uganda, new political and social capital was gained by cultivating connections with organizations and funding sources abroad. These connections often depended on a facility for engaging with American conservative agendas privileging accountability and personal responsibility. Perhaps most devastating for Uganda was the way in which behavior change was set in opposition to other approaches to HIV/AIDS prevention. In the wake of PEPFAR, Uganda’s broadly inclusive approach to program development was strongly challenged. Christians involved in prevention often told me that they wanted to change the meaning of Uganda’s ABC prevention plan from “abstain, be faithful, and use condoms” to “abstain, be faithful, and lead a Christian lifestyle,” seeking Christianity’s prominence in and dominance over disease prevention efforts.

      The immediate effects of PEPFAR were felt most keenly among NGOs who sought to apply for program funds. Uganda’s prevention approach became more heavily fractured after PEPFAR’s implementation, with organizations forced to account for how their programs supported specific PEPFAR funding areas. Sometimes a program’s content had to be changed in order to satisfy these requirements. The prominent youth-focused group Straight Talk Uganda removed discussions about condom use from its educational radio shows after the American organization distributing PEPFAR funds to the group insisted that it do so.⁷³ The founder of that organization, a British national who has lived in East Africa since the mid-1980s, told me how the environment surrounding prevention work became more politically tense in the years following PEPFAR’s implementation. The message of abstinence also became, in her words, “more rigid” and was increasingly informed by a Western view that understood sex to be driven by “only two things: desire and love.” Programs that addressed the broader cultural context that informed decisions about sexuality in Uganda (for instance, Uganda’s zero grazing program) were replaced by others better adapted to American grant requirements.

      In order to seek PEPFAR funds, groups had to categorize themselves as addressing singular program areas, such as “abstinence/be faithful” or “condoms and related activities,” that did not necessarily reflect the ways Ugandans had previously imagined and categorized prevention strategies. These classifications left little room for the more nuanced partner reduction messages that the Ugandan ABC program had been known for. Public perception of PEPFAR in Uganda was also that it heavily favored prevention programs focused on abstinence. In its report on the impact of PEPFAR in 2005, Human Rights Watch quoted one Ugandan youth: “With funding coming in now, for any youth activities, if you talk about abstinence in your proposal, you will get the money. Everybody knows that.”⁷⁴ PEPFAR’s own program report from 2005 also emphasized this focus, stating in the Uganda country section, “U.S. programming is increasingly emphasizing both A[bstinence] and B[e faithful].”⁷⁵

      The increase in donor funds for AIDS prevention also exacerbated the business-driven aspects of AIDS research and advocacy, in which a program’s dependence on donor aid worked to reshape objectives to meet or synchronize with donor concerns. This was a problem not limited to AIDS funding, but its effects were keenly felt in the realm of Ugandan HIV/AIDS prevention. The director of Janet Museveni’s Uganda Youth Forum, a youth-focused AIDS prevention NGO, articulated this dilemma when he told me in 2011 that, at the end of a grant’s cycle, “You are left with unfinished business. But when the next resource comes you have either become irrelevant or they are focusing on another development area.” PEPFAR represented a dramatic ramping up of both treatment and prevention programming, but it was marked by many of the problems that plague international aid in general. The terms of its funding were defined and driven by political agendas far removed from Ugandan communities. These agendas reshaped which messages were privileged and which became “irrelevant.” Another long-term AIDS researcher in Uganda told me, “To me, the response to HIV/AIDS in Uganda was more effective before than it is now. Right now I see the overcommercialization—the overtechnicalization, and then the commercialization. People respond to money, not to the problem. The period before [now] there was no money. People were responding to the problem.”

      As international aid funding patterns have shifted, international NGOs devoted to HIV/AIDS prevention and treatment have become increasingly important social and economic institutions in Uganda. The effect of PEPFAR on Ugandan NGOs was perhaps most apparent in the rapid mobilization of Christian organizations, both local and international, that became involved in HIV/AIDS work. Large U.S.-based Christian NGOs played especially important roles in the implementation of PEPFAR; the largest grants under the 2003–8 program went to treatment projects (80 percent of PEPFAR’s funds are dedicated to treatment), but international Christian NGOs, including World Vision and Samaritan’s Purse, received significant grants for prevention.⁷⁶ Other smaller evangelical Christian NGOs, including some started by Ugandans, have also received funds. In 2007 Shepherd Smith, the missionary who testified before Congress, received a grant for abstinence and faithfulness programs on behalf of his NGO, the Children’s AIDS Fund. His organization in turn relied on two Ugandan subpartners, Janet Museveni’s Uganda Youth Forum and the Campus Alliance to Wipe Out AIDS, the latter founded by a Ugandan born-again pastor.⁷⁷ Both of these programs were dedicated to promoting an abstinence-only approach to youth education.⁷⁸

      These and other born-again organizations played a role in establishing the strong emphasis that Uganda’s PEPFAR grantees have placed on abstinence and faithfulness as prevention strategies. In 2007, 39 percent of all of PEPFAR’s primary grant recipients in Uganda listed abstinence and faithfulness as one of their program areas.⁷⁹ In 2008, PEPFAR’s own statistics note that of 6.3 million Ugandans reached through prevention programs, more than 72 percent received an abstinence and/or faithfulness message.⁸⁰

      The emphasis on abstinence and faithfulness is not in itself radical in a country that for nearly fifteen years emphasized behavior modifications to reduce HIV prevalence. What changed dramatically under PEPFAR was how this message was being conveyed to the Ugandan population. Uganda’s early program was thought to be so effective in part because it heavily relied on peer-to-peer education and locally produced content to educate about HIV prevention. The message about behavior risk was also integrated with other prevention messages, including partner reduction and condom use education, rather than viewed as a separate program area.

      In Kampala in the years following PEPFAR’s introduction the immediate sense was that AIDS prevention had become contentious and politicized in ways it had never been before. The experience of Straight Talk Uganda, whose program leader felt the group was on tenuous ground because its programs were not perceived as sufficiently proabstinence, gives only a partial picture. Prevention was a political issue, one shaped by international aid and Uganda’s relationships with U.S. conservative lawmakers. In the years following PEPFAR’s introduction, religiously infused prevention activism became a platform on which students and other young people could advocate for new attitudes about sex that were viewed as more aspirational, more empowering, and (from certain perspectives) more “moral.” Troublingly, these messages were often placed in opposition to other prevention strategies that had previously been common in Uganda (the “zero grazing” program, or Straight Talk Uganda’s long-form radio shows that emphasized peer-to-peer sexual education) as well as those approaches that most often contrasted with behavior change in global debates about prevention during this period (biomedical interventions such as serostatus testing and condom distribution).

       A Fractured СКАЧАТЬ