factors contribute to a community’s experience of health and well-being.
PART I
The Context of a Policy
1
AMERICAN COMPASSION AND THE POLITICS OF AIDS PREVENTION IN UGANDA
When President George W. Bush introduced the President’s Emergency Plan for AIDS Relief (PEPFAR) in his 2003 State of the Union address it was remarkable for many reasons, but most notable was the dramatic shift it represented in the U.S. government’s stance toward HIV/AIDS. It was not until 1986, a full five years after health officials began to track the spread of the epidemic in the United States, that President Ronald Reagan publicly uttered the term AIDS for the first time.1 His long silence, a veritable erasure of the epidemic from official concerns during his first term in office, reflected a broader attitude of fear and indifference that permeated the Reagan administration’s response to the rapidly unfolding health crisis.2 Federal financing for AIDS-related research was also severely limited early on, in large part because of the opposition of prominent conservative politicians in Congress. Senator Jesse Helms, one of the most vocal of these opponents, gained notoriety for his declarations that the disease was the result of “deliberate, disgusting” conduct and thus was undeserving of scientific attention.3 In the 1995 congressional debate over the reauthorization of the 1990 Ryan White Act, one of the first American policies that sought to secure care and treatment for Americans living with HIV/AIDS, Helms argued against refunding it. He told a reporter for the New York Times that “we’ve got to have some common sense about a disease transmitted by people deliberately engaging in unnatural acts.”4 Helms and his peers espoused the view that those who were dying of AIDS had behaved irresponsibly, even sinfully, and that these moral indiscretions made them accountable for their pain.
Given this, it is striking that less than a decade later President Bush, himself a conservative Republican, announced a global program to combat HIV/AIDS that is considered by many to be one of the largest and most important public health policies ever deployed. In his 2003 State of the Union address, Bush movingly argued that government policies are, at their best, vehicles for the personal compassion and care that Americans demonstrate to those in need everyday. Describing South African AIDS patients dying without access to treatment, Bush argued that PEPFAR represented a “work of mercy” capable of transforming the lives of millions suffering around the world.5 With the stroke of his pen, AIDS moved from the margins to the forefront of U.S. health and global agendas. Even more remarkably, the AIDS patient was transfigured from the deserving sinner of 1980s urban America to the suffering victim (often in Africa, and often a woman) whose image seems so irrevocably linked to the epidemic today. What had precipitated this apparent about-face in how American conservatives viewed HIV/AIDS?
This question shadowed the early stage of my research in Uganda. In interviews I conducted in July 2004 with American and Canadian missionaries living in Kampala, the impact of PEPFAR was already evident. Members of Christian organizations that until that year had had limited involvement in HIV/AIDS treatment and prevention programs spoke to me in moving terms about their plans to become engaged with the issue and seek PEPFAR funds.6 One middle-aged Canadian man told me how he had recently been “called” to the issue of HIV/AIDS and was expanding his mission’s programs to address the epidemic. But the embrace of the issue was not without some conflict. Another missionary, someone who had dedicated most of his adult life to Ugandan relief work, confessed that until that year he had been little involved in AIDS programming, in large part because the U.S. churches that supported his work did not consider the issue to be central to a Christian mission like his. He explained that because HIV/AIDS was associated with “immoral behavior” it was difficult to find funding from religious American donors for such programs. Another missionary couple, who coordinated an AIDS education program funded by USAID, told me that they had prayed for a year, seeking to overcome their conflicting feelings about AIDS, before taking on the project. These views were not particularly uncommon. As Christine Gardner recounts in her study of U.S. sexual abstinence programs, a donor survey conducted in 2000 by the international Christian nongovernmental organization World Vision—just three years before Bush introduced PEPFAR—revealed widespread resistance among Christians to funding HIV/AIDS programs in Africa—even those serving orphaned children. One problem that World Vision leaders identified was the perception that AIDS sufferers “deserved their fate.”7
For many of the Christian aid workers I spoke with that summer, the ground shift that precipitated their involvement in AIDS programming was related to changes in the ways AIDS patients themselves were perceived. No longer viewed as victims of their own misguided behavior, people suffering from AIDS—especially in places like Uganda—were seen as deserving candidates for compassionate intervention and aid. The introduction of PEPFAR, with its stipulations reserving a percentage of prevention funding for “behavior change” programs, bolstered the perception that AIDS prevention work could be a platform for social transformation and moral intervention. Moreover, Bush’s faith-based policy initiative, which he had introduced in 2001, allowed for the broader engagement and direct federal funding of religious organizations in both domestic and foreign humanitarian and development work.8 The couple above who were in the process of implementing their AIDS education program pointed to the faith-based policy as the reason they had taken on that project. The woman told me that “the U.S. [federal government] would fund our programs in the past—relief work and the like—but this AIDS curriculum development program? No way.” Her implication was that the federal government had long considered most nonemergency humanitarian work done by missionaries to be outside the legal parameters of federal funding guidelines, which prohibit the support of projects that have a primary focus on religious proselytizing.9 But now, under President Bush, religious and community organizations had been broadly encouraged to compete for federal funding and to occupy a more central role in the administration of a wide range of social services. On the ground in 2004 it seemed that PEPFAR and related U.S. federal policies were transforming the ways North American religious organizations considered the scope and impact of charitable and humanitarian intervention in Uganda.
In this chapter, I trace the significance of these shifts in attitude and engagement by considering the emergence and effects of an ethic of compassion within U.S. political discourse, an ethic that under President Bush’s leadership came to shape how and why social welfare and international aid programs—and especially AIDS prevention programs—were pursued. My focus on compassion is an effort to analyze the underlying rationales that gave rise to PEPFAR in the early years of the twenty-first century, as well as the effects—intended and unintended—that followed the policy’s implementation. My primary focus in the first half of this chapter is on American moral sentiments and ambitions: what drove American contributions to HIV/AIDS relief and prevention in Africa, and what forms did such contributions take? My second aim is to explore the immediate effects of American compassion on the tenor of AIDS activism and on the landscape of AIDS prevention in Uganda. How was the American approach different from others that had—famously and successfully—preceded it? And, perhaps more significantly, what forms of social action and approaches to health and wellness did American compassion, with its ensuing emphasis on personal accountability, help generate?
America’s Armies of Compassion: Making the Accountable Subject
President Bush’s decision to address the global HIV/AIDS epidemic grew out of his efforts to develop what is now widely described as his “compassionate conservative” approach to governance. In the 2003 State of the Union address, Bush explained why he believed compassion should play a fundamental role in government policy. “Our fourth goal,” he noted, “is to apply the compassion of America to the deepest problems of America. For so many in our country—the homeless, and the fatherless, the addicted—the need is great. Yet there is power—wonder-working power—in the goodness
