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