Preaching Prevention

Born-Again Christianity and the Moral Politics of AIDS in Uganda

Lydia Boyd

• Publisher: Ohio University Press
• Year: 2015
• eBook ISBN: 9780821445327
• Topic: Social Sciences
• Subtopic: Diseases & Allergies
• Index: Social Sciences

Preaching Prevention examines the controversial U.S. President's Emergency Plan for AIDS Relief (PEPFAR) initiative to "abstain and be faithful" as a primary prevention strategy in Africa. This ethnography of the born-again Christians who led the new anti-AIDS push in Uganda provides insight into both what it means for foreign governments to "export" approaches to care and treatment and the ways communities respond to and repurpose such projects. By examining born-again Christians' support of Uganda's controversial 2009 Anti-Homosexuality Bill, the book's final chapter explores the enduring tensions surrounding the message of personal accountability heralded by U.S. policy makers.

Preaching Prevention is the first to examine the cultural reception of PEPFAR in Africa. Lydia Boyd asks, What are the consequences when individual responsibility and autonomy are valorized in public health initiatives and those values are at odds with the existing cultural context? Her book investigates the cultures of the U.S. and Ugandan evangelical communities and how the flow of U.S.-directed monies influenced Ugandan discourses about sexuality and personal agency. It is a pioneering examination of a global health policy whose legacies are still unfolding.

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 and idealism and faith of the American people. Americans are doing the work of compassion every day: visiting prisoners, providing shelter for battered women, bringing companionship to lonely seniors. These good works deserve our praise, they deserve our personal support and, when appropriate, they deserve the assistance of the federal government.”¹⁰ In the context of a federal policy speech, “compassion” invokes an ideal of the benevolent state, a government that identifies need and suffering and acts to address it. Yet Bush’s compassionate conservativism sees compassion not as a value that the state itself possesses but one provided by its citizens.¹¹ It is a policy goal that seeks to pave the way for the empowerment of the private sector and private individuals who may address need and show compassion in their everyday lives, theoretically reviving a sense of civic responsibility and restoring the balance of moral governance in American society. Bush famously referred to charities and religious groups as “armies of compassion,” better equipped than the state to address social problems like homelessness and poverty.¹² This was a compassion effected through the nurturing of a relationship not between the state and its needy citizens but between the state and a private sector sanctioned to serve the needy—battered women and lonely seniors—in ways believed to be more efficient and effective than those undertaken by the government itself.

This shift underscores how Bush’s interpretation of compassion was marked by a broader inflection of neoliberal principles in his approach to governance and international aid. In the wake of 1990s domestic welfare reforms, individuals and the private sector were encouraged to participate in work previously relegated to the state and in turn were made more responsible for their own and their community’s well-being.¹³ The state’s role in social programs was criticized by conservative backers of such reforms as inefficient, lumbering, and part of a legacy of progressive Democratic approaches to the problems of poverty that had supposedly created a relationship of dependency, rather than accountability, between citizens and the state. In the 1990s public policy rhetoric in the United States increasingly emphasized qualities like personal empowerment, self-esteem, and individual responsibility as the end products of a new free-market-dominated system characterized by looser labor regulations and a global corporate system hinged to a post-Fordist strategy of “flexible capital accumulation.”¹⁴ In the wake of these reforms, Bush’s “compassionate” turn injected the image of the caring state back into the public consciousness. Yet the language of compassion, like these earlier policy endeavors, transferred the onus and responsibility of social services onto the citizen-volunteer, who was emboldened to take charge of social problems in lieu of state services.

The rise of a volunteerism as an expression of civic duty and as a key element of the transformation of the late capitalist state has been well documented.¹⁵ President George H. W. Bush’s famous “thousand points of light” speech, made at the 1988 Republican National Convention, presaged the celebration of volunteerism as an essential aspect of new forms of citizenship and social action that would come later. The Big Society program of British prime minister David Cameron provides a more contemporary corollary for how volunteer organizations have been heralded as essential tools through which society may compensate for the reduction of social welfare programs. Andrea Muehlebach’s analysis of an emergent “moral” form of citizenship at the heart of the northern Italian neoliberal state has highlighted some of the key contradictions behind these trends;¹⁶ her study of voluntarism in and around Milan from 2003 to 2005 notes how the heightened political emphasis placed on volunteer organizations during this period was driven by the desire to create a new “species of citizen” whose unpaid charitable productivity would fill the gaps created by a retreating postwelfare state.¹⁷ Yet, contrary to a purely critical analysis, Muehlebach argues that the effect of this trend has been to complicate depictions of the neoliberal state as purely a rationalizing, amoral project. Similar to American conservative discourse, Italian reformers emphasize the emotional social bonds that are enhanced through volunteer labor; citizens are encouraged in Milan to “live with the heart,” the message being that personal sentiment may animate state policy and make it more effective.¹⁸ In this way the rise of volunteerism in Italy has been embraced by formerly critical sectors of society—such as the Communist Party and labor unions—for the ways in which such reforms are believed to generate new forms of “solidarity.”

A notable aspect of this shift from state welfare to volunteer labor in both Italy and the United States is the way that services once considered to be the right of citizenship are encountered in this new version as a privilege, a “gift”—albeit ideally an emotionally resonate one, the product of a fraternal sentiment between citizen-donor and recipient. Marcel Mauss, in the conclusion to his famous essay on the gift, highlights connections between the emergent welfare state in early twentieth-century France and the reciprocal moral obligations that he views as emblematic of gift exchange.¹⁹ In his idealized description, the interconnections among labor unions, workers, employers, and the state create a web of obligations that ensures security and solidarity for all. But in its late twentieth-century iterations the “gift” of compassion becomes both highly personalized and one-directional. The emphasis on volunteerism reimagines the gift of social services as unrequited, a demonstration of care in the face of abject need, seemingly given without expectation of compensation or reward. As much as the language of compassion sought to empower and mobilize American and European volunteers, it also undermined the agency of those who received aid. The needy were not partners in such works of compassion, viewed as members of a broader interdependent society, but instead were characterized as recipients of their neighbors’ benevolence and care. The “right” to health care, safe housing, and food is reinterpreted in conservative language as a problem of “entitlements,” a system that emphasizes the dependency, rather than the productivity, of the poor.

The context of international aid shifts the dynamic of the relationship of citizen and state to one of donor and recipient, but many of the effects of this rhetorical turn remain. The idea of compassion may be contextualized as part of the broader emergence in recent years of a “politics of care” that has shaped contemporary responses to humanitarian crises worldwide.²⁰ Erica James describes the “political economy of trauma” in Haiti as a “compassion economy,” one that “can transform pain and suffering into something productive.”²¹ As Miriam Ticktin points out in her study of French asylum policies, the emergence of care as a platform for governance has shaped the subjects of the state’s concern in particular ways.²² The compassionate response is provoked by images of suffering, the recognition of a “morally legitimate” subject whose abject physical need compels our action. Drawing on Michel Foucault’s notion of “biopower,” a term he coined to explain the mechanisms through which life becomes the object ...

Table of contents

• Cover
• Series Page
• Title Page
• Copyright
• Dedication
• Contents
• List of Illustrations
• Acknowledgments
• Introduction
• Part I. The Context of a Policy
• Part II. Engagements
• Part III. In a Policy’s Wake
• Notes
• Bibliography
• Index