so dramatic, and so unexpected, that it has been dubbed a “miracle” of HIV prevention success. By the early years of the twenty-first century, Uganda’s national prevalence rate was well below 10 percent of the population, and the epicenter of the global AIDS crisis had shifted to other parts of the continent.
Uganda’s “miracle” catapulted the country to the forefront of debates over HIV/AIDS prevention—debates whose stakes grew higher as global funds for treatment and prevention grew dramatically in the decades that followed. This book is about the wakes produced as this miraculous story was reclaimed, retold, used to justify certain responses to the epidemic, and adopted by politicians on both sides of the Atlantic to buttress new forms of political capital and international influence. It is a study of an American AIDS policy’s reception in Uganda, and the ways in which a policy supposedly drawn from Uganda’s early success returned there to shift the landscape of HIV activism and advocacy, engaging and reshaping long-standing arguments about sexual morality, marriage, and gender relations.
In 2003, President George W. Bush reversed a long period of intermittent action and partial measures by announcing a global AIDS policy of unprecedented proportions. Using soaring, optimistic language, Bush proclaimed that the President’s Emergency Plan for AIDS Relief (PEPFAR) represented a “great mission of rescue” that would prevent new HIV infections and save the lives of millions living with AIDS around the world. To promote HIV treatment and prevention was to enable “the advance of freedom” itself, reasserting America as a beacon of “hope” in parts of the world wrought by the epidemic’s crisis.4 The scope of PEPFAR was indeed transformative, for the first time bringing effective treatment to millions of people living with AIDS in resource-poor countries. But PEPFAR was also controversial. Of the $3 billion reserved for HIV prevention programs in targeted countries, one-third of monies were earmarked for abstinence and faithfulness-only programs. Under PEPFAR’s guidelines, these programs advocated personal “behavior change” as a frontline defense against the virus. President Bush and his advisers argued that empowering individuals to practice better self-control—by delaying sexual debut and remaining “faithful” to spouses—was the best remedy for an epidemic that had confounded public health officials worldwide. But critics in the United States and abroad viewed these stipulations as needless restrictions on aid, siphoning money away from other types of prevention programs, such as access to HIV testing, the promotion of condom use, and broad-based sexual education.5 More pointedly, others argued that such stipulations were made solely to forward Bush’s political agenda, and especially to appease his evangelical Christian supporters, who had newly embraced the AIDS epidemic as the frontline in a battle to reassert religious values in American policy making.6
With its emphasis on self-empowerment and personal accountability as pathways to disease management, PEPFAR dovetailed with other trends in conservative American policy making of the 1990s and the early years of the twenty-first century, a period defined by neoliberal strategies emphasizing the weakening of state welfare and the expansion of global free-market capitalism. An ethic of “self-help” pervaded policy reforms of this period, cultivating individual will and personal empathy as stand-ins for diminishing state resources.7 Under PEPFAR the Bush administration emphasized approaches to AIDS prevention that were predicated on an individual’s ability to manage and control his or her own exposure to disease risk. The term behavior change, which became a touchstone in debates over AIDS prevention policy during this period, was appealing to its supporters for the ways it focused attention on individual autonomy in sexual behavior. Like U.S. welfare recipients, participants in PEPFAR-funded prevention programs were compelled to become more responsible for their own care. If one could make better decisions about when and with whom one had sex—if one could abstain, or remain “faithful” in marriage—HIV risk could in theory be reduced or eliminated.
PEPFAR’s “great mission of rescue” was intended to alleviate the far-off suffering of, most prominently, African victims.8 But if PEPFAR was in part a project intent on ending the suffering wrought by the epidemic, it was also something more than a humanitarian endeavor. It was a global health program of unequaled scope, a project that sought to intervene in behaviors and beliefs about sexual relationships, medicine, and family life in order to better address the crisis. American “compassionate” sentiment helped form particular approaches to international governance and aid, approaches that were invested not only in recognizing and alleviating suffering but also in managing and “empowering” suffering populations and individuals. This American response helped outline a particular object of its care—what I call the accountable subject: a model for healthy behavior that, as I will discuss throughout this book, conflicted with other approaches to health and well-being in Uganda. Accountability was an approach to public health that emphasized individual responsibility for disease prevention; one that envisioned the locus of disease risk in personal behavior and choice, rather than broader structural, economic, and social factors that might also contribute to well-being. It was animated by a Western cultural orientation to health that places value on the virtues of physical autonomy and independence. In Uganda, where health has long been considered in part a function of the social and spiritual relationships one has with others, a message of self-reliance as the best pathway to healthiness had its limits.
This book considers the effects of these shifts in U.S. policy making from the point of view of the Ugandan born-again Christian AIDS activists who embraced Bush’s restrictions on HIV prevention funding and celebrated what they termed a more “moral” approach to solving the problems of the epidemic. By 2004, when I began this research, Ugandan religious institutions, especially nondenominational and Pentecostal born-again churches, emerged in a way they never had before as key players in debates over AIDS prevention, seeking out newly available funds through PEPFAR to organize teach-ins advocating youth abstinence and protests against “sexual immorality.” Kampala’s university campuses were awash with prayer groups meditating on the value of “sexual purity.” Saturday night discos competed with gospel-infused revivals where students were admonished to “keep their underwear on!” Ugandan born-again Christian arguments about what constituted moral behavior were shaped not only by President Bush’s “compassionate conservative” intentions but also by long-standing debates over the nature of family and kinship obligation and the role of women in Ugandan society. Emboldened by the interest and attention of conservative American Christians, born-again churches in the capital city of Kampala became key sites where “accountability” was actualized and put to use by Ugandan youth, at times with unexpected results.
In its focus on Ugandan activists, this book takes up the adoption and implementation of a global health program by Ugandans themselves, tracking the ways international agendas are repurposed to address culturally and historically specific experiences related to gender, family, and sexuality. Public health programs, especially those like PEPFAR, which are concerned with the intimacy of family life and sexuality, are programs that forward powerful moral claims about what it means to act healthily. The seemingly unassailable ethics that underlie dominant approaches to global health today—particularly ideals like accountability—are never neutral. There is, to echo the anthropologist James Ferguson, a “politics and anti-politics” to global health miracles.9 That is, humanitarian projects like PEPFAR claim a moral imperative that seems to place it outside the realm of politics. To alleviate suffering is ostensibly an act beyond political motive, even as the compassionate sentiments that underlie such projects help shape particular approaches to governance. The story of Uganda’s early AIDS prevention success was a product of this antipolitical humanitarian realm: embraced as a politically disinterested story of human triumph even as it was used to buttress and validate certain approaches to care and humanitarian relief, approaches that worked to create particular kinds of subjects for American compassion.
If this is a story about the ways a health policy travels, it is also a study of how African recipients of a public health program took up and transformed a lesson about accountability, emphasizing both the appeal and the limitations of a global approach to AIDS prevention. PEPFAR was a policy that circulated, from its roots in Uganda’s early success to its formation in the United States, and back again; and with each iteration it was
