Part 2 comprises chapters 3–5, which examine the meaning and practice of abstinence and faithfulness within a community of Ugandan born-again Christians. These chapters highlight how this message was refigured within Uganda to address the particular moral and spiritual struggles that young people encountered. Chapter 3 is the first of two chapters to examine the message of abstinence. The chapter focuses on how abstinence was framed as a certain type of (Christian, neoliberal) moral message and the ways it was compared and contrasted with other forms of sexual education in Uganda that emphasized different types of moral subjecthood. It includes an examination of how youth made sense of and resolved the moral disjunctures that abstinence created, and how such negotiations both established the strategy’s appeal and demarcated its limitations as a public health approach. Chapter 4 focuses specifically on how abstinence was evaluated in terms of Ugandan frameworks for health and healing. It explores how abstinence was a practice driven by forms of spirituality and experiences of embodiment that diverged from Euro-American and biomedical orientations to health. I suggest that the ability to reframe abstinence in terms of these local orientations to spirituality and embodiment played a large part in how and why this became a popular health message within the Ugandan born-again community.
Chapter 5 examines the message of faithfulness as a prevention strategy and interprets how a message about planning for marriage was shaped by intergenerational conflicts in contemporary Kampala. I highlight especially how these conflicts played off young men’s feelings of marginalization in the contemporary economy and how a message about AIDS prevention that asked them to withdraw from sexual relationships—usually a key measure of status for young men in Kampala—could succeed when paired with other neotraditional messages about gender relations and marital and household dynamics.
Part 3 begins with chapter 6, which serves as a coda for my ethnography of the church community as it focuses on the years after the end of the first phase of PEPFAR funding—a period when activism within the church expanded beyond AIDS prevention to address a wider array of concerns over sexual behavior. During this period members of UHC emerged as key participants in the antihomosexuality movement in Uganda, a series of protests that culminated in 2009 with the introduction in parliament of a bill that would radically intensify criminal punishments for men and women identified as homosexuals. This chapter analyzes the controversy over Uganda’s Anti-Homosexuality Bill as part of the longer struggle to manage sexuality and gender relations in the late twentieth and early twenty-first centuries in Kampala.59 In particular, it considers ideas about sexual personhood and sexual rights in Uganda today, and some of the problems faced by international and local groups that seek to protect gay Ugandans by building on rights-based arguments for sexual equality. Chapter 6 provides a window on how social activism within the church has changed in light of changing relationships with American Christians and a somewhat transformed political climate in the United States. Exploring the implications of accountability within other humanitarian endeavors, this chapter contributes a discussion of how efforts to extend the platform of human rights to include sexual minorities in Uganda has engaged and broadened many of the moral dilemmas I articulate earlier in the book.
Finally, this book’s epilogue revisits the concept of accountability as a key framework for global health projects. In the years following the end of PEPFAR’s initial grant period (2003–8), when abstinence and faithfulness fell out of favor as a dominant prevention strategy adopted by the U.S. government, members of UHC reflected on their role in a global AIDS prevention project. Their sense of frustration at the changing priorities of foreign funders revealed some of the limitations of global health partnerships that supposedly emphasize individual empowerment and personal accountability without acknowledging the ways that cultural, moral, and structural factors contribute to a community’s experience of health and well-being.
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