and “moral” behavior. PEPFAR’s emphasis on “behavior change” reflects the dominant ethos underlying approaches to humanitarian care and global health today, but it was, on the ground, an approach that was contested in practice, reshaped by Ugandan orientations to moral behavior and well-being that conflicted with the American ideal of “accountability.” In this sense, the story of PEPFAR challenges the unidirectional image of global health: one in which Western countries create and fund programs outlining models for care and healthiness and Africans simply adopt such models.
In the following chapters I explore how “behavior change”—with its particular emphasis on an ideal of personal accountability—was an approach to prevention that was formed by a historical moment in the United States and Africa. It was an approach characterized by neoliberal economic policies that emphasized the individual—rather than the state, kin group, or community—as the central agent in processes of development and social transformation. The shape of the “accountable subject” is evident everywhere now, from messages like PEPFAR’s, in which the self-controlled, abstaining individual is the key to disease management, to rural development projects where, as Tania Li has argued, individual will drives social improvement schemes.10 In Uganda, neoliberal policies have reorganized institutional and state apparatuses, but they have also effected changes in the experience of moral personhood and the evaluation of moral conduct. What sorts of subjects are made legible by approaches to governance that demand that subjects become more “accountable” for their care, and with what consequences?
The larger impact of humanitarian aid and global politics was felt not only in the presence of PEPFAR’s programs but in the changing nature of Ugandan society, where older values predicated on the interdependence of youth and elders were being challenged by discourses emphasizing an “entrepreneurial” spirit and the benefits of young people’s initiative and independence. “Accountability” was a discourse that stoked deep tensions over the costs and benefits of such changes to society. Young adults felt these tensions keenly as they struggled to imagine their own futures and families. Uganda’s born-again churches were at the center of these transformations, adopting a message of personal “success” and moral asceticism in the face of a rapidly changing social environment—where everything from gender equality to conspicuous displays of wealth provoked moral rebuke and concerns about the state of Ugandan culture and values.
These broader shifts in AIDS prevention and activism have affected experiences of health and well-being in Uganda. The emergent emphasis on individual will and personal agency helped reinforce a new and distinct way of being an ethical sexual subject in Uganda—one that diverged from other messages about moral conduct that existed alongside it. In Uganda, as in many African societies, the liberal ideal of the rational, autonomous person that animates so many modern institutions and values—from Western biomedicine to the project of human rights to the ideal of accountability itself—coexists with other models for personhood, and especially those that construe the person as defined not by the qualities of interiority and autonomy but instead by experiences of social interdependence and obligation to others. In Uganda, relationships of interdependence between members of kin groups and between patrons and clients are critical ways social actors constitute their place in the world, and forge a moral and social identity. Ugandan experiences of personhood were in many ways counterposed to the message of individual accountability and independence that the PEPFAR program promoted.
In Uganda, these older models for moral personhood became critical touchpoints in debates over the concept of accountability as both a mode of prevention and a model for behavior. PEPFAR’s emphasis on accountability could provoke dilemmas for Ugandan young adults, who were also taught that their assertion of independence, especially through their withdrawal from social and sexual relationships, could in certain instances be viewed as dangerous, immoral, or antisocial. In southern Uganda, where the pursuit of health has been characterized by one historian as a “collective endeavor,”11 how did people make sense of a message that emphasized autonomy in decisions about sex and wellness? This book concerns itself with these sorts of conflicts: What does it mean to speak of a “self-empowering” approach to health care? What sort of moral agency is being advanced by an emphasis on choice and self-control? How did young Ugandans navigate the underlying conflicts inherent in the message of accountability? And, most significantly, how did this message come to affect the politics and experiences of health, disease, and family life in Ugandan communities?
The argument of this book is twofold. The first part is that the accountable subject reflects a particular approach to governance that has come to dominate contemporary frameworks for global health. Today in Uganda, as in much of the world where humanitarianism is at work, demonstrating a will to improve is the way one becomes a visible subject for nongovernmental endeavors. In this new model, one’s claim to certain services—access to clean water, education, health care—is no longer the rights-based claim of a citizen, nor a claim rooted in forms of traditional community-based obligation. Rather, access to humanitarian and nonstate aid becomes dependent on one’s ability to demonstrate accountability for one’s condition, to be a good subject of compassion, and to be able to harness the will to be improved by a donor’s humanitarian attentions.12
The second and more prolonged argument of this book is that this approach to health and healing is animated by particular moral sentiments and ethical dispositions that are contested in practice. Decisions about health are broached as moral conflicts, and to understand the effects of a global policy like PEPFAR we need to better understand the diverse models for moral agency and personhood that define the pursuit of health in particular settings. In Uganda, the values that inhabited accountability—to be autonomous, self-sufficient—were experienced in tension with other ways of being that were also understood to define the experience of health. Health in Uganda was not expressed solely as the good management of one’s interior, physical state. Moral and physical well-being depended also on the proper management of one’s obligations to and relationships with others—relationships that were believed to directly affect one’s physical and mental state. If Americans attempted to forward an authoritative model of proper, healthy behavior marked by the emphasis placed on the virtue of being accountable for one’s own well-being, Ugandans engaged this message on more uncertain terrain. The rest of this introduction elaborates on these points and provides background information on the community where my research was conducted. I begin with a discussion of how and why accountability has come to dominate global approaches to health today.
The Accountable Subject: Biopolitical Aid and the Effects of Compassion
When I write about the “accountable subject” I mean to draw attention to a particular way of thinking about good and proper conduct—conduct that is thought to produce healthiness and prosperity and has come into focus in recent years in part through policies like PEPFAR. PEPFAR’s faith in individuals’ capacity to change—to reform their behaviors—formed the core of its policy directives.13 It was rooted in an underlying belief that both moral good and socioeconomic good follow from the actualization of ideals like independence, autonomy, and personal freedom. And it differs from other popular approaches to disease management—for instance, methods that encourage technological interventions, such as an increase in serostatus testing or the development of a vaccine, or methods that encourage structural changes that address socioeconomic or other inequalities linked to health risk, such as gender differentials in education or high rates of domestic violence. PEPFAR emphasized only one type of prevention approach in its funding stipulations, requiring that one-third of monies directed to prevention, US$1 billion, be used for “abstinence and faithfulness” education. So why—and why now—have the ideals of self-control and personal accountability come to govern public health regimes, especially those concerned with AIDS prevention?
An ethic of self-regulation seems to have intensified in recent years alongside changes to dominant forms of state and international governance. Beginning in the 1980s, two interrelated trends began to shift the field of economic development—and in turn, health care—in Uganda: the first was the expanding influence of a neoliberal economic
