neoliberal governance and humanitarian compassion helped shape new ways of thinking about being a good, proper, and moral person in Kampala. But as may already be apparent, the terms compassion and accountability are embedded in particular frameworks for understanding persons and agency that were far from universal in Uganda. A key tension that surrounded the adoption of behavior change emerged from its difference from—and occasional overlap with—other ways of acting as a good, productive, and moral person. As I will discuss throughout this book, the practices attributed to being an accountable subject were contested, emerging as an assemblage of global policy and local moral subjectivities that reshaped Ugandan orientations to health and well-being in the years following PEPFAR’s adoption.
Morality and Public Health
The first part of this book’s argument, which I have outlined above, is that PEPFAR is a policy defined by the conjuncture of neoliberal economic forms and an emergent humanitarian ethos in international aid, which together have helped outline the accountable subject at the center of global health. The second part of this argument is that the neoliberal concern with accountability is one animated by moral sentiments that were contested in practice. Public health programs, especially those that seek to prevent disease, are projects that intercede in broader moral debates, creating models for behavior that outline individuals’ responsibilities to themselves and to each other. The message that PEPFAR forwarded—to become more accountable for one’s health by avoiding HIV/AIDS—was a choice that was constrained by a number of economic and social factors. But abstaining, and becoming accountable, was also a choice that was viewed as a pathway to being a certain type of (moral) person in Uganda. Throughout this book I consider how decisions about health are often experienced as moral conflicts that highlight competing models for how to be good, healthy, and successful. To better understand the ways public health messages are interpreted in varied cultural settings, we need to be better able to recognize the role of diverse models for moral agency and personhood in the pursuit of health and wellness.
When I use the term public health, I refer specifically to the Western discipline familiar to most readers, under which a program for AIDS prevention, like those supported by PEPFAR, might fall. But the term also relates to a broader category of projects encompassed by the terms social health and public healing,31 which have been used to describe African practices of healing as collective endeavors, ones that are at the center of projects to maintain and secure social welfare. Neil Kodesh’s study of public healing rituals in precolonial Buganda has highlighted the ways that such rituals emphasized the connections between “a community’s moral economy and continued well-being.”32 Studies of healing in Africa have long underscored how practices that seek to manage health extend beyond addressing the physical ailments of suffering individuals to consider the broader social and moral context of health and prosperity.33 In communities across Africa, people’s relationships with each other, with a spiritual realm, and with their environments have long been factors that were considered to shape and intervene in experiences of health and illness. Even as there is much to distinguish modern public health projects from this longer history of African public healing, both sorts of projects attempt to forward a notion of social order that is predicated on specific moral orientations and sets of obligations.34 Modern public health projects set out to teach people to subordinate their personal desires and interests for the broader public good: “Cover your mouth when you sneeze.” “Kitchen workers must wash their hands before returning to work.” Public health programs are also projects that seek to inculcate models for healthy behavior within the public or social (and moral) context that gives our experiences of healthiness and social obligation shape.
Given this broader context, this book explores what a more explicit consideration of morality might bring to our understanding of health, and of global health programs in particular. To understand how AIDS prevention messages were engaged by Ugandan youth, we need to understand not just how health and well-being are linked to clinical practices or evaluations of physical risk but also the ways health is also a product of “moral imaginings and moral expressions.”35 Our moral perspective on the world, or what the anthropologist T. O. Beidelman has called our “moral imagination,” is the frame through which our experiences of sickness and healing—in fact, the entirety of our social world—is defined and coped with.36 A central aspect of the human experience is the way we confront uncertainty through practices of moral reflection: we imagine and speculate about others’ and our own pain and suffering. Our moral imagination also provides us with the ability to “scrutinize, contemplate and judge” our world,37 to imagine what is and what might be different. It may be understood to “map the ambiguity of social experience”;38 it is how we make sense of uncertainty and change. Perhaps because of this, anthropologists’ interest in the topic of morality has focused in particular on the problems of navigating and making sense of radical social changes. In several recent ethnographies, the study of morality has provided a way of understanding and analyzing the contradictions between indigenous ways of life and the ethical orientations associated with modernity.39 This has been especially true of studies of contemporary Islam and Christianity.40 Christian conversion has been noted for the ways in which it can precipitate a radical reconfiguration of social and cultural forms, marked especially by a sense of discontinuity between older values predicated on social cohesion and interdependence, and a modern-Christian emphasis on the value of individual agency, moral interiority, and personal autonomy.41
As much as social changes and social crises (such as the AIDS epidemic) have elicited a sense of disjuncture and discontinuity, in practice such conflicts are almost never experienced as linear and distinct.42 One benefit of a focus on the ways people engage moral norms is that it provides us with a more nuanced understanding of how individuals make sense of social changes and the competing values attributed to different ways of being.43 The crisis surrounding AIDS and its prevention is addressed on such moral terms in Uganda not so much as a problem of right and wrong, or as a problem addressed through the dictates of a certain religious doctrine or biomedical decree, but on terms that seek to define and establish the outlines of personhood and moral obligation. In the communities where I worked, I found that the American emphasis on accountable behavior was taken up and transformed by youth as they pursued multiple, often contradictory, messages about how to be good, healthy persons. As much as abstinence seemed to emphasize a neoliberal focus on the individual, in practice it also reinforced other, older models for sexual subjecthood. For instance, as I discuss in chapter 4, Ugandan youth viewed abstinence as something more than the cultivation of self-control and personal responsibility. They also viewed abstinence through frameworks for spiritual and community well-being that emphasized the strength of an individual’s relationships with others. As an embodied practice, abstinence (along with its partner message, faithfulness) mediated between the seemingly opposed experiences of autonomy and interdependence in neoliberal Uganda and the cultural and ethical meanings that lay beneath both ideals. A focus on the moral conflicts that are rooted in neoliberal approaches to governance and global aid provides us with a better understanding of the effects of such policies and of the role of African subjects in implementing and transforming these projects.
In the pages that follow I consider how health is pursued as a component of moral personhood and explore abstinence and marital faithfulness as ethical practices—or, following Foucault, “technologies of the self” by which young Ugandans sought to make themselves into certain kinds of moral persons. Foucault’s notion of ethical practice—that ethics is a matter of self-cultivation governed by practical “techniques” that guide conduct—has proved valuable to anthropologists because it establishes an understanding of ethics that emphasizes the quotidian practices that generate culturally variable ethical and moral subjects.44 Such analysis allows us to understand moral behaviors and choices not only as products of sovereign will governed by Kantian reason but also as actions shaped by variable forms of social power. In this schema, ethical practice may be analyzed as generative of multiple experiences of personhood, not dependent on a privileging of the autonomous post-Enlightenment
