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God and the Fight Against AIDS

At one of these events, I watched a pastor in a silk suit and patent leather shoes warn an enormous crowd against the sins of fornication, homosexuality, pornography, and “nude dancing”—the striptease shows that have recently become popular in the capital. He healed people’s livers, backaches, and broken legs, passed around gigantic collection baskets, and jitterbugged vigorously to Christian rock hymns accompanied by a chorus of Ugandan youths. Around one third of the Ugandan population has been “born again” in the past decade, and new churches are springing up in warehouses, shacks, school auditoriums, and village clearings. At traffic circles in the center of Kampala, men in black suits waving Bibles preach through glimmering exhaust fumes to stalled commuters. Two of Uganda’s four TV stations beam in religious programs from around the world, twenty-four hours a day, and quotations from scripture have become part of everyday speech.

Shortly after I arrived, I paid a visit to Martin Ssempa, the pastor who burned the condoms at Makerere. He is an authority on abstinence education in Africa and has given presentations at USAID and led the prayer at Mrs. Museveni’s March of Virgins. Ssempa runs a church and sponsors a Billy Graham–style sex- and alcohol-free abstinence rally every Saturday night on Makerere’s campus. In his sermons, he condemns homosexuality, pornography, condoms, Islam, Catholics, certain kinds of rock music, and women’s rights activists, who he says promote lesbianism, abortion, and the worship of female goddesses.7 He told me that Satan worshipers hold meetings under Lake Victoria, where they are promised riches in exchange for human blood, which they collect by staging car accidents and kidnappings. In his headquarters, just down the hill from Makerere, there is a special room for exorcisms.

Ssempa is stocky and bald, with a broad avuncular smile. He wears colorful Hawaiian-style shirts and wire glasses. Although born in Uganda, he spent years in the US and his Ugandan accent has a warm American twang. We talked about Satan, homosexuals, pornography, and other sins, and he asked me whether I had any idea where he could obtain $4 million to buy land for his church. Our meeting was interrupted by numerous phone calls. As I listened and took notes, he shouted in English and Luganda. There had been some sort of crisis. Population Services International—or PSI—a secular organization that had been distributing condoms in Uganda for years, had recently received US government funding to carry out an abstinence program. PSI had used the money to produce a new comic book in which the main characters, a teenage boy and girl, flirt with each other, make out on a couch at her house, and then decide to abstain from sex. In one of the frames, they walk by a condom billboard on the street.

Look at this!” Ssempa yelled, pointing at the drawing of the condom billboard. “It’s horrible. You can’t promote condoms and abstinence at the same time!” It would only confuse young people, he said, and send the message that it was really OK to be promiscuous.

They won’t get away with it. I have spoken to the First Lady’s office. We need to ensure that George W. Bush’s money gets into the right hands,” he told me, “Those who are doing abstinence-ONLY, as determined by the legislation.”

Last fall, Ssempa and his congregation prayed fervently for a Bush victory in the US presidential elec-tion. He reminded me of the African bureaucrats who played the US and the Soviet Union off each other during the cold war. This time, it was a battle over moral rather than political ideology, but just as in the cold war, a rich country was using foreign aid to fight its battles in developing countries. Now that there is finally a huge amount of money for AIDS programs in Africa, a scramble for it now appears to be underway in Uganda, and faith-based groups like Ssempa’s are going to considerable lengths to get rid of the organiza-tions that have been receiving US government contracts for years, especially those that promote condoms.8 This could have serious consequences, because condoms have helped to control Uganda’s epidemic. HIV infection rates fell most rapidly during the early 1990s, mainly because people had fewer casual partners.9 However, since 1995, the proportion of men with multiple partners has increased sharply. Condom use increased at the same time, and this must be why HIV infection rates have remained low.

But condom programs in Uganda are now threatened. Under pressure from both the Ugandan and US governments, billboards advertising condoms, for years a common sight throughout the country, were taken down in December 2004. Radio ads with such slogans as “LifeGuard condoms! Ribbed for extra pleasure!” were to be replaced with messages from the cardinal of Uganda and the archbishop about the importance of abstinence and faithfulness within marriage. In November 2004, Engabu, a highly popular Ugandan condom brand, was pulled from the shelves because of alleged problems with its manufacture. At the same time, the government now insists that all condoms entering the country be subjected to additional quality control tests. However, Uganda does not have the equipment to carry out such tests, and this has resulted in a shortage of condoms.

Meanwhile, American evangelical Christian magazines such as Citizen, published by Focus on the Family, a Washington, D.C., organization that lobbies against gay rights and abortion, and World, edited by Bush adviser Marvin Olasky, have claimed that USAID is pouring money into condom programs in Uganda and ignoring abstinence and monogamy, which, according to the articles, are the only interventions that really work.10

Condoms have a controversial history in Uganda, and official attitudes toward them tend to shift with the ebb and flow of US government funds. During the 1980s and early 1990s, condoms were not widely available in Uganda, and many people did not believe they really worked. The government did not promote their use and religious leaders denounced them as immoral and “un-African.”11 Health experts at USAID and other international agencies were concerned about this because they were skeptical that Uganda’s existing AIDS programs would work. In 1986, the Ugandan Ministry of Health had launched a campaign known as “Zero Grazing”—Ugandan slang meaning “don’t have casual sexual relationships,” but did not promote condoms.

Then, in the early 1990s, the World Bank, USAID, and other donor agencies set out to make condoms more appealing, not only to citizens, but also to policymakers and religious leaders. By then, population experts had had considerable success encouraging the use of a variety of contraceptives—all initially unpopular—in other developing countries, with an approach known as “social marketing,” which uses advertising and marketing techniques to encourage people to adopt healthful practices. They had found that when condoms and other contraceptives were distributed free of charge in bland medical packaging, people found them unappealing. But when packaged in bright, colorful sleeves, and advertised on billboards and radio spots as sexy and fun, they were much more popular.

Selling condoms in shops, even at very low prices, rather then distributing them free, also added to their cachet. In Uganda, USAID began funding condom social marketing programs in the early 1990s. At the same time, the agency increased funding for the Ministry of Health, the Uganda AIDS Commission, and various church-affiliated organizations run by some of the leaders who most vocally denounced condoms. This new funding had the effect of toning down public criticism of condoms. Meanwhile, the Zero Grazing campaign was gradually phased out.

By the late 1990s, international contractors that specialize in social marketing, such as Population Services International, authors of the comic book that Ssempa complained about, were selling hundreds of millions of condoms each year in Africa. Organizations like PSI don’t make money on the condoms they sell, but they do obtain lucrative government contracts to carry out social marketing programs. Uganda’s social marketing campaigns were especially dynamic, and, as the Makerere student informed me, condoms had become part of Ugandan culture.

Then, shortly after Mrs. Museveni returned from Washington in 2003, where she had helped Republicans lobby for the $1 billion appropriated for abstinence programs, Ugandan officials resumed denouncing condoms after a ten-year hiatus. In a speech at an international meeting of AIDS experts in 2004, President Museveni said AIDS was “a moral problem,” caused by “undisciplined sex,” and that condoms should be reserved for prostitutes. Mrs. Museveni has accused those who promote condoms of racism. “They think Africans cannot control their sexual drives,” she said in a speech last year. “We will prove them wrong!” She has warned young people that organizations that promote condoms are only after their money. On a similar note, Information Minister James Butoro, like Mrs. Museveni a born-again Christian, accused condom social marketing organizations of “profiteering.”

As it happens, Mrs. Museveni’s Uganda Youth Forum (UYF) began receiving US funding to promote abstinence only until marriage to young Ugandans in 2004.12

A large number of new faith-based abstinence organizations like Ssempa’s Campus Alliance to Wipe Out AIDS (CAWA) and Mrs. Museveni’s UYF have sprung up in Uganda in recent years, including the Glory of Virginity Movement (GLOVIMA), the Family Life Network (FLN), and American groups such as True Love Waits. Many of these organizations hope to receive US funding from the $1 billion appropriation for abstinence-only education. US law forbids organizations receiving federal funds from evangelizing, but every abstinence event I attended involved much praying and discussion of Jesus. As Human Rights Watch points out, it was sometimes hard to tell what the aim of these organizations actually was—preventing AIDS or saving souls.

While I was in Uganda, I met Emily Chambers, a pleasant twenty-six-year-old woman who is in charge of AIDS programs in East Africa for Samaritan’s Purse, a US-based charity run by Billy Graham’s son Franklin that had just been chosen to receive a multi-million-dollar US government contract to carry out HIV prevention programs. Among other things, the organization plans to train African Christian pastors to carry out abstinence-only education.

I knew that Samaritan’s Purse was in favor of abstinence-only, but inevitably some of the pastors they plan to train will be approached by people wanting to know more about condoms. I asked Ms. Chambers whether Samaritan’s Purse would recommend that pastors refer such people to other organizations. “We don’t know about that yet,” she said. But when I asked her about the role of faith in abstinence programs, her eyes opened wide. “It’s HUGE,” she exclaimed. “Abstinence is near impossible without the helping hand of the Lord.”

Later, I met a group of girls who were members of GLOVIMA, the Glory of Virginity Movement, a Ugandan abstinence club run by an evangelical church. When I asked them how they intended to ensure that their future husbands would be faithful to them, only one hand went up. A little girl in a tartan dress stood up very straight and said, “I will pray for him.”

  1. 7

    See also Andrew Rice, “Evangelicals vs. Muslims in Africa: Enemy’s Enemy,” The New Republic, August 9, 2004, and Human Rights Watch, “The Less They Know, the Better.”

  2. 8

    Similar funding battles between HIV prevention groups focused on abstinence and those focused on condoms are underway in other African countries. See Center for Health and Gender Equity, “Where Is the ‘C’ in ABC.”

  3. 9

    See Rand Stoneburner and Daniel Low-Beer, “Population-Level HIV Declines and Behavioral Risk Avoidance in Uganda,” Science, April 30, 2004, pp. 714–718. A previous report attributed the decline in infection rates in Uganda mainly to condom use and abstinence. (See Asiimwe-Okiror et al., “Change in Sexual Behaviour and Decline in HIV Infection Among Young Pregnant Women in Urban Uganda,” AIDS, Vol. 11, No. 14, November 15, 1997, pp. 1757–1763.) However, this report miscalculated partner reduction. The authors report that the proportion of people with casual partners—defined as relationships lasting less than a year—fell very little between 1989 and 1995. However, instead of calculating the proportion of all sexually active people who have casual partners, the authors reported only those people who were in long-term relationships—lasting more than a year—who also had casual partners. In other words, they omitted from their calculation all those who had partnerships lasting days, weeks, or months only. This population contains many young people who are at very high risk of HIV. When they are included in the calculation, the proportion of those with casual partners fell by around 60 percent, as Stoneburner and Low-Beer have shown.

    Recently, various US newspapers suggested that increased condom use and the death of AIDS patients were the main reasons for the decline in HIV infection rates in Uganda. See Lawrence Altman, “Study Challenges Abstinence as Crucial to AIDS Strategy,” The New York Times, February 24, 2005; and David Brown, “Uganda’s AIDS Decline Attributed to Deaths,” The Washington Post, February 24, 2005.

    These news reports were based on a study from the Rakai district of southern Uganda that has been underway for more than a decade. The reports on the study were misleading for several reasons. First, although AIDS certainly increased death rates in Uganda, it has done so throughout eastern and southern Africa. However, HIV rates in Uganda fell by 75 percent in the 1990s, but have since risen or stabilized everywhere else. The HIV epidemic in Zimbabwe, Zambia, and Malawi began only a year or two after Uganda’s. If deaths from AIDS were the main reason for Uganda’s decline, we should by now have seen huge declines in HIV infection rates similar to Uganda’s in these countries. However, HIV rates in these countries today are between three and five times higher than they are in Uganda, and have fallen very little, if at all, during the past fifteen years.

    Because HIV infection has no cure, deaths need to occur for HIV prevalence to decline. What happened in Uganda (but not elsewhere) is that sexual behavior changed, so that when people died of AIDS, they were not replaced by an equal number of newly infected people. In other countries, there has been very little prevalence decline, despite a great many deaths. See also Albert H.D. Kilian et al., “Reductions in Risk Behaviour Provide the Most Consistent Explanation for Declining HIV-1 Prevalence in Uganda,” AIDS, Vol. 13, No. 3 (1999), pp. 391–398.

    Although increased condom use probably has contributed to the decline of HIV infection rates in Uganda, it is unlikely to have been the main reason for this success. The survey of sexual behavior in Rakai district referred to in Brown’s and Altman’s articles was conducted between 1994 and 2003. However, there appears to have been significant behavior change in Rakai and throughout southern Uganda before 1994, which the study described in the news articles did not measure. According to scientific reports on the Rakai project (see references below), HIV rates in Rakai fell rapidly between 1990 and 1996, and much more slowly, if at all, thereafter. In 1990, the HIV prevalence rate in Rakai trading centers was around 35 percent. In 1996, it was around 16 percent. Today, it is around 14 percent. Condom use began to increase rapidly in Rakai only in the mid-1990s. In 1996, when the decline in HIV prevalence was well underway, only 12 pecent of people surveyed in Rakai had used a condom in the six months preceding the survey. Thus it is unclear how it is possible to claim that condoms were the main reason for the decline in infection rates that occurred before 1996. Nor was death, or abstinence, for that matter. (See Maria J. Wawer et al., “Dynamics of Spread of HIV-1 Infection in a Rural District of Uganda,” BMJ, November 23, 1991, pp. 1303–1306; and Maria J. Wawer et al., “Control of Sexually Transmitted Diseases for AIDS Prevention in Uganda: A Randomised Community Trial, Rakai Project Study Group,” The Lancet, February 13, 1999, pp. 525–535.

    Consistent with the findings of Low-Beer and Stoneburner, focus groups conducted in Rakai itself during the 1980s and early 1990s showed Zero Grazing and “sticking to one” were the most commonly reported responses to the question “What are you doing to protect yourself from HIV?” (See for example Joseph K. Konde-Lule et al., “Focus Group Interviews About AIDS in Rakai District of Uganda,” Social Science and Medicine, Vol. 37, No. 5, September 1993, pp. 679–684.)

  4. 10

    See Priya Abraham, “Hooked on Failure,” World, November 6, 2004; and Candi Cushman, “Burying the Truth,” Citizen, March 2005.

  5. 11

    See Maryinez Lyons, “The Point of View: Perspectives on AIDS in Uganda,” in AIDS in Africa and the Caribbean, edited by George Bond et al. (Westview, 1997).

  6. 12

    Some of the money for Mrs. Museveni’s program is to be channeled through the Children’s AIDS Fund or CAF, a US organization. In November 2004, CAF, which is run by a couple who are close friends of President Bush, was promised US government funding, even though the grant proposal it submitted to USAID was deemed “unfit” by a review panel. USAID administrator Andrew Natsios argued that CAF had ties with Janet Museveni’s Uganda Youth Forum, who “is a pioneer in abstinence and be faithful messages,” and should therefore be given special consideration. Randall Tobias, the US Global AIDS coordinator, apparently agreed. CAF was formerly known as Americans for a Sound AIDS Policy. In the 1990s, it lobbied to increase federal funding for “Abstinence-only- until-marriage programs,” and against extending Americans with Disabilities protection for people with HIV. The disbursement of funds under the President’s Emergency Plan for AIDS Relief is disturbingly opaque. According to the Center for Health and Gender Equity, an organization that tracks US government spending on reproductive health, millions of dollars disbursed so far have not been publicly accounted for, in addition to that promised to CAF. See David Brown, “Group Awarded AIDS Grant Despite Negative Appraisal,” The Washington Post, February 16, 2005, p. A17.

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