Uganda’s “Miracle,” and Sociostructural Components of Prevention
Rapid political changes emphasizing democratic participation and the increasing leverage of women and youth in local politics provided the critical backdrop to HIV programs of the 1980s and 1990s in Uganda. Contrary to his later incarnation as a Western-friendly advocate of open-market reforms, Museveni’s early politics were influenced by his training at the University of Dar es Salaam in the late 1960s, a period defined by the expansion of Tanzanian president Julius Nyerere’s Ujamma (African socialist) reforms. In publications during his first decade in power Museveni voiced an idealistic desire to politically mobilize the peasant classes in Uganda, and his early policies emphasized reforms of local government structures to encourage broad-based participation.49 He has recently come under strong criticism for his long-held resistance to multiparty democracy (only retracted before the 2006 elections) and his iron grip on political leadership in Uganda,50 but when he came to power in 1986 he was widely viewed as a political reformer who championed democratic governance and resisted corruption. The party leadership of Museveni’s National Resistance Movement (NRM) opposed discrimination based on gender, age, education, and ethnicity.51 Women and youth, traditionally groups with limited political influence, were given special consideration in electoral politics. Women’s and youth seats were reserved at all levels of government, and in the first years of NRM rule women were far more successful in their campaigns for open parliamentary seats than they had ever been before.52 Girls’ enrollment in school also increased during this period, and the new Ugandan constitution, ratified in 1994, strengthened women’s property and divorce rights.53 The position of women significantly improved in the 1980s, and they responded to these opportunities by becoming more involved and organized at all levels of society. During this same period Ugandan villages became politically revitalized and a culture of local organizing to address community issues—encouraged by the NRM’s grassroots politics—blossomed. Museveni’s government also held a privileged position during these years, buoyed by widespread trust and optimism—both domestically and in the global sphere—for the possibilities of political change and the genuineness and transparency of government leadership.
It was in this context that initial efforts to address the impact of HIV/AIDS emerged. Small rural communities in Uganda were faced with an almost unimaginably devastating epidemic in the 1980s, and the response within these communities was almost surely far more personal, small-scale, and community-centric than later efforts would be. The government and community messages surrounding HIV during this period were also clearly shaped by and responsive to local sexual attitudes. Museveni’s famous “zero grazing” phrase, adopted by Bush administration officials as an example of a Ugandan message promoting abstinence, referred not directly to sexual abstinence but to a mere reduction in the number of sexual partners.54 A comprehensive survey of Uganda’s prevention efforts in the 1980s and early 1990s emphasized that no single behavioral shift can be credited with drops in HIV incidence during this period.55 In a country where multiple concurrent partners are common, and where men view the support of multiple partners as a sign of their virility and status, many researchers argue that a message of no sex, particularly when levied at adults, would have fared poorly in these early years. Robert Thornton, an anthropologist who has studied Uganda’s prevention success, quotes an army officer as saying, “Thank God, Museveni never told us not to have sex! He would have been laughed out of the country!”56
Ugandan organizations founded during the first decade of the epidemic, such as The AIDS Support Organisation (TASO) (which early on emphasized the social cost of the epidemic on women) and the youth education group Straight Talk Uganda were highly effective in using peers to educate about HIV/AIDS, encouraging open discussion of a previously taboo subject and disseminating information in a culturally sensitive manner. Peer-to-peer education has been shown to be particularly effective in making disease risk a personal matter and creating a stronger sense of social pressure to adhere to behavior changes.57 Tellingly, Ugandans are more likely than any other Africans to have received information about HIV/AIDS from peers, as well as to have known someone personally living with the disease.58
In the 1980s and 1990s people in Uganda changed their behavior, delaying sexual debut and reducing their number of sexual partners. But such changes in behavior were also supported by significant structural shifts that had encouraged women and youth to take more active social and political roles in the country.59 Moreover, the government supported an integrated, multisectoral approach to prevention that did not privilege any singular message or policy.60 AIDS was a very real crisis; communities and the Museveni government responded by attempting to mobilize people against the disease, to talk about it candidly, and to use multiple approaches toward education and building awareness. Uganda’s success was dependent on the individual actions of people who followed the ABC (abstain, be faithful, use condoms) message that became famous by the end of the 1990s, but such individual decisions depended in turn on a broader set of social and structural changes that involved communities in the response to the epidemic, worked to reduce the stigma of living with and speaking about AIDS, and encouraged women and youth to organize and address the different ways in which the epidemic affected certain groups.61
By the year 2000, the broader set of structural changes that had accompanied HIV prevention success were overshadowed by a narrowed focus on individual accountability and self-control as primary tactics of disease management. Behavior change reflected the rhetoric of the neoliberal reforms of this new era, privileging values like autonomy and self-sufficiency. Yet as I have briefly outlined here, a drive toward self-control had not always been the dominant message regarding HIV/AIDS in Uganda. As the nation’s success circulated to the global level in the late 1990s, the story of its precipitous drop in HIV prevalence was applied as support for a broader U.S. political agenda that sought to emphasize the correlation between compassionate aid and the redemptive possibilities of personal accountability. Thornton recounts how USAID officials who had sponsored his research in an effort to prove that behavior change was the root of Uganda’s success became dissatisfied when his work argued instead that abstinence had not been a key component of Uganda’s early program.62 By 2003, when PEPFAR was introduced, the narrative of Uganda’s success had become contested terrain as various stakeholders sought to redefine why and how behaviors changed. This was nowhere more apparent than in the discussions that surrounded the initial funding of PEPFAR.
Ugandan Behaviors and U.S. Congressional Debates over PEPFAR
During the U.S. congressional debates that preceded PEPFAR’s funding, Uganda’s prevention strategy and the reasons for its success were strongly contested along political lines, with Republican lawmakers and Bush administration officials emphasizing the importance of abstinence and marital faithfulness to Uganda’s ABC strategy and Democratic lawmakers resisting this characterization of Uganda’s success. Testimony before the Senate and House subcommittees charged with addressing the new initiative demonstrated how Ugandan prevention policies were refracted through U.S. political and cultural divisions, leading to the program stipulations outlined in the 2003 legislation that funded PEPFAR. In one of the first of these meetings Representative Lois Capps, a Democrat from California, and Shepherd Smith, an American missionary with ties to the Bush administration, each framed Uganda’s success quite differently.63 Capps emphasized the integrated approach of Uganda’s program and noted that abstinence alone had not been effective in Uganda, noting, “Reports from USAID and U.N. AIDS indicates [sic] that comprehensive and community-based approach to HIV/AIDS prevention works best. The fundamental goal of these public health interventions is to change behavior and it appears that Uganda’s use of integrated behavioral change programs has had remarkable success. There is also no evidence that abstinence works alone. There is no data that sufficiently reports abstinence only rhetoric as causally decreasing rates of HIV/AIDS in Africa.”64 Smith—who, with his wife Anita, had founded a Christian NGO in Uganda—directly responded to Capps’s comments, challenging her emphasis on an “integrated behavioral change” strategy: “I think that it’s important to remember that this isn’t ABC in the context that