Hooked on failure

Africa | In Africa's fight against AIDS, the United States continues to support family-planning groups that stifle the White House abstinence and fidelity message

Issue: "Post-party election blues?," Nov. 6, 2004

Before the Bush Administration, the United States fought AIDS in Africa and around the world with one weapon: condoms. Under President George W. Bush, the emphasis became abstinence and faithfulness-a program with Christian roots and a successful track record in Uganda, where AIDS has declined dramatically. But, with millions in AIDS-fighting dollars rolling out under Mr. Bush and results now rolling in, condoms are still winning out.

Global condom distribution by the United States under the Bush administration has tripled from five years ago.

U.S.-funded programs distributed 190 million of the contraceptive devices in 1999. This year they will hand out 550 million. Despite the mounting evidence that abstinence programs are more effective in reducing AIDS rates, old public-health habits are dying hard.

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"It's worse than nothing's changed," said Edward Green, a senior research scientist at Harvard. Mr. Green visited Uganda in August, having spent 20 years fighting AIDS in Africa and working as a behavioral science specialist at Harvard's School of Public Health. Despite the administration's new AIDS rhetoric, Mr. Green said he found no signs of an extreme makeover in Uganda. "The unique indigenous program that Uganda developed is being gradually destroyed," he told WORLD.

When Uganda became the first African country to beat back its AIDS epidemic, Mr. Bush adopted its "ABC" prevention model as U.S. policy. It became the trademark of his Emergency Plan for AIDS, a $15 billion, five-year program to fight the disease. Fifteen countries, including Uganda, are to benefit from the plan.

"ABC" stands for Abstain, Be faithful, or use Condoms in the case of high-risk groups such as prostitutes. The approach fostered healthy behavior among most of the population and helped drive down Uganda's HIV rate from 21 percent in 1991 to about 6 percent today.

In January Congress appropriated the emergency plan's first $2.4 billion. Of that, $80 million was devoted to Uganda. But instead of pursuing faith-based and other groups geared to the ABC model, the U.S. Agency for International Development (USAID) office in Kampala has funded old-school family-planning groups who have peddled millions of condoms to Africa for years. Contraceptive supplier Population Services International (PSI)-a Washington, D.C.-based nonprofit organization-received the first installment of $12 million in abstinence and faithfulness funds. A further $2 million is earmarked for faith-based groups. But it will be distributed by a consortium of five large aid groups led by CARE International, groups long recognized as hostile to an abstinence-focused mission.

Long-term planning for Ugandan AIDS policy is also in the wrong hands. The Deliver Project, funded entirely by USAID, is mapping the logistics of condom, drug, and other contraceptive distribution to continue fighting AIDS the old way. Last year it pressed the Ugandan government to craft a condom policy that tracks condom usage and effectiveness.

Mr. Green now speaks of "salvaging" the country from the grasp of U.S. and other Western donors: "We're going to reach a point where infection rates will start going up again and then experts will say ABC never worked, that there was probably something wrong with the data all along."

Mr. Green's warning is noteworthy: Once a condom social marketer himself, he has become a crusader for Uganda's ABC approach through firsthand research in Africa, testifying before Congress and now serving as a member of the Presidential Advisory Council on HIV and AIDS. He returned to Uganda in August at the request of Janet Museveni, alarmed herself by U.S. funding trends.

Mrs. Museveni, along with her husband, President Yoweri Museveni, devised ABC in 1986 in the face of a burgeoning epidemic and armed with only meager state funds. With little Western interference-Uganda was emerging from the disastrous dictatorship of Idi Amin-they relied on low-cost measures to change people's sexual behavior. They told teenagers to abstain until marriage, and told the sexually active to employ "zero grazing"-a catchphrase for staying faithful to one's partner. Studying Uganda's success, Mr. Green discovered that the emphasis on fidelity had the most impact. But now, the homegrown AIDS treatment revolution is struggling under U.S. influence. "Uganda is being pushed more towards condoms and pills," Mr. Green said.

The local USAID mission is pushing hardest, using PSI Uganda. Until last year, the group functioned under a family-planning project of USAID's population office that did social marketing. "Social marketing" is industry lingo for commercial-style campaigns aimed at changing people's behavior. In Africa, the term is synonymous with selling and promoting low-cost condoms. In October 2003, PSI assumed full management of the project's social marketing, absorbing its donor funding from USAID and the Centers for Disease Control and Prevention.


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