Given this emphasis on rational choice, projects of development and economic restructuring in the neoliberal state have come to emphasize the individual, rather than the state or community, as the central actor in projects of social transformation.19 Daromir Rudnyckyj, writing about similar economic changes in Indonesia, calls this period the “afterlife of development,” an era marked by the shift from state-sanctioned investment to an era in which “this duty is transferred to the citizens themselves,” who are made to feel both more empowered and also more accountable for state services that may no longer be taken for granted.20 It is this aspect of neoliberalism that interests me. What happens when the pursuit of health in a place like Uganda is viewed through the lens of the rational individual decision maker?
The realms of biomedicine and public health may be particularly fruitful arenas in which to explore this emergent emphasis on individual accountability. Foucault’s lectures on “biopolitics” have highlighted the ways the physical body have become a more explicit focus of governance in the modern era.21 Biopower, according to Foucault, is enacted both in the policies that manage populations (such as those that regulate reproduction and population growth) and in the new ways individuals are taught to regulate and manage the body itself. More recently, scholars have proposed concepts such as “biological” and “therapeutic” citizenship to describe how biology and physical need have become key resources through which individuals stake claims to state and nonstate resources.22 If the body has become a more explicit focus for rights and regulations, it is also now increasingly conceived of as an optimizable resource.23 We are taught not only that we are responsible for ourselves but that our bodies and our experiences of physical health are the means through which we may improve and become more responsible citizens. As perhaps they have never been before, our bodies are the means by which we are governed and learn to govern ourselves.
When I note that PEPFAR’s key prevention message of “abstinence and faithfulness” may be analyzed as biopolitical sexual discourse and practice, I mean to draw attention to the sorts of ethical dispositions that abstinence and sexual self-regulation were supposed to generate: the intense focus on individual conduct as a site of economic and social transformation. In Uganda, particularly in the churches where my research was based, abstinence and marital faithfulness were spoken of as embodied practices believed to make people not only more moral but more economically successful; more “intentional” in decisions about work, family, and relationships; and more accountable for their mistakes. Abstinence and marital faithfulness were believed to cultivate a new, more productive young adult, empowered to embrace her own potential, more self-reliant, autonomous, and “invested” in herself. This rationalization of conduct was undertaken often at the expense of other ways of addressing social crisis: through forms of community organizing or large-scale structural changes to government or state. The “accountable subject” reflects these particular ideas about health and wellness, the ways that Ugandans in the early years of the new century were being taught, and at times were refiguring, a message that told them they could be empowered by making better personal choices about their bodies and avoiding the risks associated with disease and infection.
If neoliberal rationality and new forms of biological governance have given shape to the present-day onus on personal accountability, the accountable subject has also emerged in tandem with a particular humanitarian ethos that has refigured international aid and the relationship between Africa and the West. The changes that followed the adoption of structural adjustment in Uganda may be most noticeable in the mechanisms that organize aid and relief operations in Uganda. In President Yoweri Museveni’s first decade in power, international donor aid to Uganda expanded more than tenfold.24 But beginning in the 1980s, donor countries increasingly sought to shift grants away from state-led development programs and toward a development sector dominated by nongovernmental organizations. The privatization of aid has been swift and dramatic in places like Uganda. Between 1990 and 1998 the total amount of aid managed by nongovernmental organizations (NGOs) in Africa more than tripled, from US$1 billion to US$3.5 billion.25 During a similar period the World Bank saw a fourfold increase in the percentage of its projects managed by NGOs, from less than 10 percent in 1990 to more than 40 percent in 2001.26
International aid has not only been directed toward a more diffuse, privatized sector but has also increasingly been defined to address “humanitarian,” rather than explicitly political or economic, needs. The pursuit of health in the Global South has been especially affected by such shifts. HIV/AIDS, an epidemic of unprecedented proportions, has caused a state of crisis that demands immediate intervention. Health is imagined in this context not as a project of optimization, as it is in wealthy countries, but as one of exception. Humanitarianism may be distinguished from other historical and philosophical approaches to transnational aid by its explicit concern with human suffering. In the humanitarian state, physical need is the central recourse through which citizens and others make claims to scarce therapeutic resources and other forms of government care.27 This state of crisis creates a differential in treatment that distinguishes experiences of health and disease in places like Uganda from those in the Global North. Anthropologists Miriam Ticktin and Vinh-Kim Nguyen have argued that the act of linking aid to a demonstration of acute physical distress is problematic because the very exceptionality of this state closes off other ways of advocating for rights and access to care. In his study of AIDS treatment programs in West Africa, Nguyen asks, “What forms of politics might emerge in a world where the only way to survive is to have a fatal illness?”28 What does it mean to view health as a state of exception, and health care as a practice pursued through a lens of “experimentality,” a term Adriana Petryna uses to point to the inequalities that shape global health and medical research?29 The global health industry—which extends beyond humanitarian aid to include medical research, a realm where seemingly marginal and unregulated, yet needy, populations like those in sub-Saharan Africa figure prominently as test cases30—has helped refashion what it means to be healthy, and how healthiness is sought out, in places like Uganda. The accountable subject is also a product of these developments, where healthiness is pursued on paths of limited resources, and where the ability to demonstrate need, and become an “appropriate” subject of care, matters most.
Both 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.