the economic and political relationships he fostered with the West.44 The state’s reliance on international aid expanded significantly during the first two decades of his rule.45 And, as was the case in other parts of the world during this period, there were changes in the manner in which that aid was distributed. The aid world had become radically decentralized during the 1980s and 1990s, with direct state-to-state aid becoming a less popular model for donors.46 Nongovernmental organizations (NGOs) and faith-based organizations emerged as critical players in the local management of donor funds.47 These trends redefined the landscape of AIDS care and treatment in Uganda, a sector that has seen the expansion of medical research projects fueled by donor funds.
Museveni’s speech in Bangkok highlights many of these trends, especially in the way he links economic restructuring to a successful HIV prevention strategy he calls “behavioral change.” In the years just prior to the Bangkok conference, behavior change emerged as a popular term highlighting individual accountability in health care choices. In Museveni’s speech, avoiding disease risk by delaying sex and by promising faithfulness within monogamous relationships were celebrated as choices that buttressed other economic and political changes in Uganda. As Ugandans became more accountable, empowered, and self-reliant citizens, their nation supposedly also became more economically viable, more democratic, and better able to manage the epidemic that had ravaged its populace. In Museveni’s words, control of the epidemic was an “individual responsibility” and within “individual means.”
In fact, this language of self-sufficiency in many ways obscured the heavily community-based approach that Ugandans had embraced in the early years of the epidemic—strategies that emphasized accountability not only to one’s self but to others, including those infected and at risk. Early prevention education emphasized peer-to-peer counseling rather than any top-down centralized curricula. Women’s groups, newly empowered in the early years of the Museveni government, had organized themselves to address the impact of the epidemic on communities and families. But in a global context that emphasized neoliberal structural reforms, behavior change came to stand for liberal democratic ideals steeped in the rational, autonomous individual. One Ugandan public health student I interviewed in 2010 succinctly characterized the shifts from the 1980s to early years of the twenty-first century in Uganda when she said, “In the eighties there was a sense of communal vigilance [about HIV]. Communities became vigilant and aware of each other. It is not the case anymore. It is more about individual aid. [Prevention], now it’s your call.” By Museveni’s calculation, behavior change seemed to represent these broader shifts in global sources of power and influence as well as the changing Ugandan economic and political context that marked early twenty-first-century life. Behavior change was a “technology of citizenship,” to use Barbara Cruikshank’s term, a mode of governance that has proliferated in the neoliberal era and “work[s] on and through the capacities of citizens to act on their own.”48
What is most remarkable about the global adoption of behavior change is the way it came to replace earlier Ugandan strategies that focused more on community transformation than individual accountability. Long before there was widespread international focus on AIDS in Africa, Ugandans had in fact changed their behavior in ways that helped reduce HIV, but by the years of the new century the term behavior change had come to stand for something more particular than changing when and with whom one had sex. Perhaps more troublingly it was a term that obscured the broader structural shifts within Ugandan society that had made “changing behaviors” more feasible for many.
Uganda’s “Miracle,” and Sociostructural Components of Prevention
Rapid political changes emphasizing democratic participation and the increasing leverage of women and youth in local politics provided the critical backdrop to HIV programs of the 1980s and 1990s in Uganda. Contrary to his later incarnation as a Western-friendly advocate of open-market reforms, Museveni’s early politics were influenced by his training at the University of Dar es Salaam in the late 1960s, a period defined by the expansion of Tanzanian president Julius Nyerere’s Ujamma (African socialist) reforms. In publications during his first decade in power Museveni voiced an idealistic desire to politically mobilize the peasant classes in Uganda, and his early policies emphasized reforms of local government structures to encourage broad-based participation.49 He has recently come under strong criticism for his long-held resistance to multiparty democracy (only retracted before the 2006 elections) and his iron grip on political leadership in Uganda,50 but when he came to power in 1986 he was widely viewed as a political reformer who championed democratic governance and resisted corruption. The party leadership of Museveni’s National Resistance Movement (NRM) opposed discrimination based on gender, age, education, and ethnicity.51 Women and youth, traditionally groups with limited political influence, were given special consideration in electoral politics. Women’s and youth seats were reserved at all levels of government, and in the first years of NRM rule women were far more successful in their campaigns for open parliamentary seats than they had ever been before.52 Girls’ enrollment in school also increased during this period, and the new Ugandan constitution, ratified in 1994, strengthened women’s property and divorce rights.53 The position of women significantly improved in the 1980s, and they responded to these opportunities by becoming more involved and organized at all levels of society. During this same period Ugandan villages became politically revitalized and a culture of local organizing to address community issues—encouraged by the NRM’s grassroots politics—blossomed. Museveni’s government also held a privileged position during these years, buoyed by widespread trust and optimism—both domestically and in the global sphere—for the possibilities of political change and the genuineness and transparency of government leadership.
It was in this context that initial efforts to address the impact of HIV/AIDS emerged. Small rural communities in Uganda were faced with an almost unimaginably devastating epidemic in the 1980s, and the response within these communities was almost surely far more personal, small-scale, and community-centric than later efforts would be. The government and community messages surrounding HIV during this period were also clearly shaped by and responsive to local sexual attitudes. Museveni’s famous “zero grazing” phrase, adopted by Bush administration officials as an example of a Ugandan message promoting abstinence, referred not directly to sexual abstinence but to a mere reduction in the number of sexual partners.54 A comprehensive survey of Uganda’s prevention efforts in the 1980s and early 1990s emphasized that no single behavioral shift can be credited with drops in HIV incidence during this period.55 In a country where multiple concurrent partners are common, and where men view the support of multiple partners as a sign of their virility and status, many researchers argue that a message of no sex, particularly when levied at adults, would have fared poorly in these early years. Robert Thornton, an anthropologist who has studied Uganda’s prevention success, quotes an army officer as saying, “Thank God, Museveni never told us not to have sex! He would have been laughed out of the country!”56
Ugandan organizations founded during the first decade of the epidemic, such as The AIDS Support Organisation (TASO) (which early on emphasized the social cost of the epidemic on women) and the youth education group Straight Talk Uganda were highly effective in using peers to educate about HIV/AIDS, encouraging open discussion of a previously taboo subject and disseminating information in a culturally sensitive manner. Peer-to-peer education has been shown to be particularly effective in making disease risk a personal matter and creating a stronger sense of social pressure to adhere to behavior changes.57 Tellingly, Ugandans are more likely than any other Africans to have received information about HIV/AIDS from peers, as well as to have known someone personally living with the disease.58
In the 1980s and 1990s people in Uganda changed their behavior, delaying sexual debut and reducing their number of sexual partners. But such changes in behavior were also supported by significant structural shifts that had encouraged women and youth to take more active social and political roles in the country.59 Moreover, the government supported an integrated, multisectoral approach to prevention that did not privilege any singular
