With its emphasis on self-empowerment and personal accountability as pathways to disease management, PEPFAR dovetailed with other trends in conservative American policy making of the 1990s and the early years of the twenty-first century, a period defined by neoliberal strategies emphasizing the weakening of state welfare and the expansion of global free-market capitalism. An ethic of “self-help” pervaded policy reforms of this period, cultivating individual will and personal empathy as stand-ins for diminishing state resources.7 Under PEPFAR the Bush administration emphasized approaches to AIDS prevention that were predicated on an individual’s ability to manage and control his or her own exposure to disease risk. The term behavior change, which became a touchstone in debates over AIDS prevention policy during this period, was appealing to its supporters for the ways it focused attention on individual autonomy in sexual behavior. Like U.S. welfare recipients, participants in PEPFAR-funded prevention programs were compelled to become more responsible for their own care. If one could make better decisions about when and with whom one had sex—if one could abstain, or remain “faithful” in marriage—HIV risk could in theory be reduced or eliminated.
PEPFAR’s “great mission of rescue” was intended to alleviate the far-off suffering of, most prominently, African victims.8 But if PEPFAR was in part a project intent on ending the suffering wrought by the epidemic, it was also something more than a humanitarian endeavor. It was a global health program of unequaled scope, a project that sought to intervene in behaviors and beliefs about sexual relationships, medicine, and family life in order to better address the crisis. American “compassionate” sentiment helped form particular approaches to international governance and aid, approaches that were invested not only in recognizing and alleviating suffering but also in managing and “empowering” suffering populations and individuals. This American response helped outline a particular object of its care—what I call the accountable subject: a model for healthy behavior that, as I will discuss throughout this book, conflicted with other approaches to health and well-being in Uganda. Accountability was an approach to public health that emphasized individual responsibility for disease prevention; one that envisioned the locus of disease risk in personal behavior and choice, rather than broader structural, economic, and social factors that might also contribute to well-being. It was animated by a Western cultural orientation to health that places value on the virtues of physical autonomy and independence. In Uganda, where health has long been considered in part a function of the social and spiritual relationships one has with others, a message of self-reliance as the best pathway to healthiness had its limits.
This book considers the effects of these shifts in U.S. policy making from the point of view of the Ugandan born-again Christian AIDS activists who embraced Bush’s restrictions on HIV prevention funding and celebrated what they termed a more “moral” approach to solving the problems of the epidemic. By 2004, when I began this research, Ugandan religious institutions, especially nondenominational and Pentecostal born-again churches, emerged in a way they never had before as key players in debates over AIDS prevention, seeking out newly available funds through PEPFAR to organize teach-ins advocating youth abstinence and protests against “sexual immorality.” Kampala’s university campuses were awash with prayer groups meditating on the value of “sexual purity.” Saturday night discos competed with gospel-infused revivals where students were admonished to “keep their underwear on!” Ugandan born-again Christian arguments about what constituted moral behavior were shaped not only by President Bush’s “compassionate conservative” intentions but also by long-standing debates over the nature of family and kinship obligation and the role of women in Ugandan society. Emboldened by the interest and attention of conservative American Christians, born-again churches in the capital city of Kampala became key sites where “accountability” was actualized and put to use by Ugandan youth, at times with unexpected results.
In its focus on Ugandan activists, this book takes up the adoption and implementation of a global health program by Ugandans themselves, tracking the ways international agendas are repurposed to address culturally and historically specific experiences related to gender, family, and sexuality. Public health programs, especially those like PEPFAR, which are concerned with the intimacy of family life and sexuality, are programs that forward powerful moral claims about what it means to act healthily. The seemingly unassailable ethics that underlie dominant approaches to global health today—particularly ideals like accountability—are never neutral. There is, to echo the anthropologist James Ferguson, a “politics and anti-politics” to global health miracles.9 That is, humanitarian projects like PEPFAR claim a moral imperative that seems to place it outside the realm of politics. To alleviate suffering is ostensibly an act beyond political motive, even as the compassionate sentiments that underlie such projects help shape particular approaches to governance. The story of Uganda’s early AIDS prevention success was a product of this antipolitical humanitarian realm: embraced as a politically disinterested story of human triumph even as it was used to buttress and validate certain approaches to care and humanitarian relief, approaches that worked to create particular kinds of subjects for American compassion.
If this is a story about the ways a health policy travels, it is also a study of how African recipients of a public health program took up and transformed a lesson about accountability, emphasizing both the appeal and the limitations of a global approach to AIDS prevention. PEPFAR was a policy that circulated, from its roots in Uganda’s early success to its formation in the United States, and back again; and with each iteration it was adopted and used by both Americans and Ugandans to forward their own ideas about the benefits of accountability, self-control, 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