Politics & Policy

Doing It Right

How that new African AIDS money should be spent.

President Bush’s bold new $15 billion AIDS initiative targeting Africa and the Caribbean debuted to positive reviews from most corners. And why not? Africa has been devastated by the AIDS pandemic, with the poorest nations on the planet, the ones least able to fight the disease and care for its victims, being the countries hardest hit by the plague. Anyone with a decent heart will commend the president of the world’s wealthiest nation for tripling its funding to help these desperate people.

And yet, there is serious reason to worry that the plan could turn into a vast boondoggle that could enrich corrupt African governments and the international AIDS establishment, while providing far too few effective measures to fight HIV infection. So say a group of AIDS experts who contend that international AIDS-fighting strategies in Africa have not succeeded because of political correctness and anti-scientific prejudice on the part of Western AIDS professionals.

In the late 1980s, when AIDS first came to Uganda, the Kampala government realized that it was being transmitted through sexual behavior. Authorities rallied religious leaders and others behind a massive campaign to convince the population to change its sexual behavior. “Zero grazing outside of your own field,” was the slogan the government used to promote its “ABC.” initiative. The message to the Ugandan people: Abstain from sex if you can, Be faithful to your partner, and if this doesn’t work, use a Condom.

It worked brilliantly. Unlike most other African nations, the HIV infection rate peaked in 1991, and has been steadily dropping since. Studies show that Ugandans dramatically reduced their risky sexual activity. And this successful program, which was devised wholly by the Ugandans themselves, could be implemented with little money.

Why wasn’t the Ugandan model embraced and emulated all over Africa? That’s a scandalous tale I tell in much greater detail in the current issue of National Review. It has to do with Western scientists, doctors, and AIDS workers having a deep suspicion of, and even antipathy for, any public-health program that smacks of moralizing, or involves religion. It also has to do with a bias in favor of expensive, medical technology-based “solutions,” despite their lack of effectiveness. The bottom line is that millions of Africans have been condemned to an early and painful death in part because the international AIDS establishment ignored the success of Uganda’s faith-based education programs.

It was thrilling, then, to see Dr. Peter Mugyenyi, director of a Uganda AIDS clinic, sitting among the president’s invited guests at the State of the Union address. Might this signal a new and better approach by the U.S. government in its AIDS-fighting strategy? There is reason to hope so. Late last year, the U.S. Agency for International Development sent a communiqué to its offices around the world, informing them that abstinence and fidelity programs would henceforth be part of America’s AIDS-fighting strategy in the Third World. If that, and now Dr. Mugyenyi’s presence at the president’s speech, indicates that the U.S. government is prepared to put lots of money into Uganda-style programs, things might really be turning around for Africa.

Emphasis on “might.” First, the good news: In a conference call with reporters yesterday, a senior administration official said that faith-based organizations overseas would be eligible to apply for some of the approximately $5 billion targeted for AIDS prevention. Mugyenyi, who was also on the call, told journalists that religious groups have been “key partners” in Africa’s fight against AIDS, and form “the very successful nucleus on which others can build.”

Here’s the not-so-good news: More than half of the money will be going into antiretroviral therapy, which is intended to reduce the number of infections by making those already carrying HIV less infectious. What about teaching personal responsibility? What’s more, the prevention funds will be dispersed according to an unspecified program in which promoting abstinence and fidelity are only two of 12 different approaches. This is dismaying, and it has insiders speculating that unless someone intervenes, serious behavior-change initiatives centered around abstinence and fidelity, the only methods proven to bring the HIV infection rate down among African populations, will be all but ignored.

“I regret that [the president] seems to suggest so much of the answer is with drugs,” says Ray Martin, a retired foreign-service officer with years of experience in African public-health programs. “I’m certainly not opposed to radically scaling up our funding for antiretroviral drugs. But a strategy that suggests the main challenge to confronting the AIDS crisis is in getting drugs to large numbers of people risks overlooking the real lesson that we’ve learned from Uganda, and to some extent [from] Senegal, Zambia, and Thailand.”

That lesson, says Martin, who now directs Christian Connections for International Health, is that entire societies must be mobilized to “change the norms and values that influence the sexual behavior of young people, and the sexual adventurism of married people.”

Edward C. Green, a Harvard researcher who has tried in vain to wake the West up to what Uganda accomplished, also welcomes the new money for AIDS treatment, but is concerned that the Bush initiative could become another case of throwing good money after bad.

“It might be expected that Ugandans and Senegalese would constitute a vocal lobbying group that would insist that AIDS prevention funds be spent in ways they know to be effective. And there are certainly some who will speak out,” says Green.

“But people in resource-poor countries everywhere have learned to play the game involved in getting donor funds,” he continues. “The name of the game is asking for what the donor organizations want to provide, namely drugs and condoms. Yes, these are both needed, but if experience to date is any guide to the future, funds would be even better spent supporting the kind of faithfulness/abstinence AIDS prevention interventions that brought down infection rates in the countries mentioned.”

Dr. Rand Stoneburner, an epidemiologist who has worked on AIDS in Africa for a variety of public-health agencies, says experience in Uganda and elsewhere demonstrates that money and the drugs it buys alone will not stop the epidemic. Putting so much money into antiretroviral therapy while not giving proven behavior-change strategies their due is a mistake, he says.

“We must support countries with a sincere commitment to provide social and political resources to turn this thing around and not create future generations dependent on foreign aid for pharmaceutical lifelong support,” Dr. Stoneburner says.

Which brings up an extremely sensitive but unignorable issue: How will the American government guarantee that its billions will be well spent? Can we be sure the taxpayer dollars intended to treat sick Africans and save others from HIV will get to the needy?

The U.S. intends to give one-tenth of the funds to the United Nations Global Fund to Fight AIDS, Tuberculosis and Malaria. As for the rest, it will be distributed directly to governments of affected countries, as well as to local and international organizations fighting AIDS. President Bush’s plan calls for the establishment at the State Department of an ambassadorial-level office to monitor the disbursement of AIDS funds to ensure accountability.

That’s good, but that office should be headed by a no-nonsense professional, an independent thinker who understands the African epidemic, but who resists the AIDS establishment’s conspiracy of silence about behavior-change and HIV. This $15 billion will be a gold mine for drug companies, donor organizations, and others who stand to profit by peddling AIDS-prevention efforts that have not worked, and will not work.

The first and only priority of this new program should be helping sick and suffering Africans, and stopping the epidemic. When Congress begins the appropriations process, it cannot let do-good sentimentality and blind trust of experts guide its decisions. This is not a matter of the “Religious Right” dictating AIDS policy (none of the professionals quoted in this article are religious conservatives, and all support the distribution of condoms, when effective). This is about doing right by the U.S. taxpayer, and more importantly, saving the lives of the poorest of the poor. Before Congress gives a farthing for the Bush plan, it should call Stoneburner, Green, Martin, and others to testify to what they know about Uganda, and why so few in the AIDS establishment want to hear it.


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