In Aids and Ideology (an early draft of which has been seen exclusively by The East African), the American anthropologist Edward C. Green reveals just how American and European donors and policy-makers used Aids-ravaged Uganda of the 1980s and 90s as an ideological battleground.
This was in “a last ditch effort to keep Aids prevention efforts free of the conviction that the sexual behaviour of Ugandans needed to change”.On his first visit to Uganda in 1993, Green had noted that the country’s Aids prevention programme seemed different from all others he had seen.
Uganda’s “Zero Grazing” initiative, introduced in 1986, not long after Yoweri Museveni came to power, was largely an African designed model of Aids prevention. It was based on the promotion of monogamy, fidelity, faithfulness within polygamous marriages, abstinence (or delay of sexual debut) and reduction of multiple sex partners.
“There is anecdotal evidence that STD incidence has significantly decreased in Uganda in the past year or two,” he wrote in his consultant’s report to USAid.”
While this may reflect wishful or politically motivated thinking, it would be extremely significant if this were true.
If a high Aids-prevalence country like Uganda shows a significant decline in STDs in the absence of a male condom prevalence rate of over 5 per cent, it might suggest other types of behaviour change. “Premarital chastity, “zero grazing”, marital fidelity, abstinence, non-penetrative and other safer sexual practices, can significantly affect incidence if not HIV incidence.”
His suspicions were confirmed in 1998 when he made his third trip to Uganda, this time for the World Bank. What Green found was that Ugandans were having fewer sex partners and that teenagers were delaying their engagement in sexual activity.
Uganda’s HIV infection rate was slashed from an estimated 15 per cent to 5 per cent in the late 1980s to the mid-1990s, miraculous by any standards and the most significant decline anywhere, then or since.
And it wasn’t only in Uganda this was happening. At around the same time, the HiV infection rate in the neighbouring Kagera region of northern Tanzania was falling.
By 1996, the HIV infection rate in the capital, Bukoba, had dropped by half and by 2003 it was down 80 per cent from its peak 15 years earlier, according to one study.
The revelation that HIV-prevalence was declining at such an early stage of the epidemic in a poor, war-ravaged region receiving little foreign assistance, and that it was doing so primarily using behaviour change, quivalent of the splitting of the atom.
It recognised human sexual behaviour change as the key to reducing HIV prevalence in sub-Saharan Africa.
But it also revealed that a unique pattern of long-term concurrent, multiple sexual partnerships existed in East and Southern Africa, which acted as a lethal “superhighway” in spreading the disease.
This strategy put Uganda firmly on the map as the most successful country in the world in the fight against Aids, though the country did also make significant improvements in the safety of its blood supplies and also promoted safer medical practices, such as using sterile injections.
Furthermore, zero grazing was cheap (Green estimates that it cost only 23 US cents per person per year to reduce HIV rates during the period 1986-91, when the most significant behaviour change occurred).
And it was also culturally relevant and sustainable in the absence of mass foreign donor support. However, such behaviour change methods were and are still largely ignored or overlooked by the international Aids community.
Green’s work challenged a multibillion dollar industry based on medical technology — condoms, testing, and drugs — and largely ignoring sexual behaviour.
Green claims that no foreign expert he met in 1993 believed that STD rates, and consequently HIV-prevalence, were declining in Uganda due to behaviour change methods.
But several African and foreign Aids research pioneers such as Lord Robert May, Charlotte Watts, Maxine Ankrah, Martina Morris, and C.P. Hudson were beginning to suspect that primary behaviour change methods were the key to counter the culture of concurrent, multiple sexual partnerships.
In spite of its success, the zero grazing strategy was gradually phased out starting in the latter 1990s, largely because foreign donors, including USAid, Pepfar and the CDC, were convinced that fidelity and abstinence had little or no relevance.
They found an HIV-positive Ugandan cleric, the Rev Gideon Byamugisha, who agreed with them. Soon he appeared at global conferences and in the halls of the US Congress explaining that the first two components of primary behaviour change methods didn’t work.
He said what Africa needed was more condoms.
For donors, the focus was on on technology and political issues such as human rights and stigma reduction. When Green wrote his consultant’s report for USAid in 1993, and his far more detailed report for the World Bank in 1998, laying out the evidence he found in Uganda, he was ignored by both.
In 2001 Green was invited to Washington to present his findings on Uganda’s unique success story to USAid headquarters. He brought a Ugandan researcher from Harvard with him, Dr Vinand Nantulyu, who had independently arrived at the same conclusions as Green.
The reaction at the meeting was not very friendly or receptive, although a paper called “What Happened In Uganda?” was published by USAid (and can still be downloaded from the USAid website).
Green’s falling out with USAid, “an organisation that had been my lifeblood for many years,” was just the beginning of what he sees as his ostracism by the global Aids industry and academia for promoting sexual behaviour change as a primary solution to Africa’s HIV/Aids epidemic.
In late 2008, the research he and his team were pursuing at Harvard University was deemed incompatible with that of other Harvard researchers were doing.
It was decided that Green’s project “was not a high priority, given all the other Aids work happening elsewhere at Harvard,” although very few at the University were working in AIDS prevention and primary behaviour change methods.
However,more and more evidence was emerging vindicating Green and his team. Pivotal articles published in major journals such as the Lancet, Science, and British Medical Journal were increasingly pointing to the need to reduce multiple and concurrent sex partners in African epidemics, and to promote male circumcision, another intervention Green and his colleagues had long endorsed.
Green’s determination to make Aids prevention evidence-based, in spite of years of rejection and personal attacks, also won him many admirers and accolades. In September 2004, he was presented with the Philly Lutaaya Award by Uganda’s President Yoweri Museveni, for his “leadership role in increasing Aids awareness through education, and looking at prevention from an African perspective.”
The 2003 publication of his groundbreaking book, Rethinking Aids Prevention led to his membership on the Presidential Advisory Committee on HIV/Aids.
During this period, he testified five times before the US Congress on global HiV/Aids issues, supporting Congressional earmarks for faithfulness and abstinence programmes.
Green was instrumental in drafting President Bush’s $15 billion dollar global anti-Aids bill, which adopted the Ugandan model and allocated a third of the total HIV prevention budget to fidelity and abstinence programmes.
However, there remained extreme resistance from the global Aids industry; what Elizabeth Pisani, the American author of The Wisdom of Whores, calls the “Aids Mafia.” Ideological differences between policy makers and implementers were also thrown into sharp relief.
“A fear-based disinformation campaign commenced, with predictions of mass death coming from all quarters, even though HIV rates had already peaked in Africa and continued to fall,” says Green.
As he tells it, “Conservatives [in the Bush Administration] focused exclusively on abstinence because, as they told me, there was a constituency for it. ‘We never really thought about fidelity.’ The great majority of implementers, though, were liberal and gay-friendly contraceptive experts whose own values and ideology made it seem wrong to ‘interfere’ with sexual behaviour.Their preferred myth was that as long as one used a condom, any sexual behaviour was alright. In the end, the ‘Uganda ABC’ policy had little impact on the ground.”
Nevertheless, Green and his colleagues at Harvard and elsewhere continue to beat the drum of “harm elimination” in the form of primary behaviour change methods, in sharp contrast to the prevailing Western Aids prevention ideology of “harm reduction,” a term first used to refer to needle exchange programmes for drug addicts.
In the early 1990s, health experts at USAid, the World Bank and other international agencies, sceptical that the zero grazing campaign would work, set out to make latex condoms more appealing, not only to ordinary Ugandans but also to policy makers and religious leaders.
A great deal of money also went into developing and promoting female condoms, which have yet to catch on in Africa.