Dennis Altman
The religious right is not simply a religious movement or a political movement; it has also, and above all, been a sexual movement. Nowhere has this been more evident than in the way the U.S. government’s involvement in the project of HIV/AIDS prevention globally was invested with a sexually conservative agenda from the very beginning.
(Herzog: 159)
For 20 years, a standard critique of US government responses to the HIV pandemic has been that it revealed a puritan distaste for sex, shown in the reluctance to support measures, such as condom promotion and support for gay and sex worker groups, which were a staple of the response in at least some other western countries. Many liked to point to the divergence between the US response and that of, say, Switzerland, the Netherlands and Australia as evidence of a significant cultural difference, rather as, several decades later, it became fashionable to juxtapose US and European values. The idea that ‘America is from Mars, Europe from Venus’, which was the name of an academic conference in Berkeley in 2006, became the popularised version of Robert Kagan’s (2003) more fundamental claim for growing divergence across the Atlantic. Kagan does not write of matters sexual, but he might well have used issues such as gay marriage and sex education to demonstrate his claims for a growing cultural gap.
The role of the USA in helping define, frame and finance the global response to HIV and AIDS far outweighs that of any other country, and the religious right has undoubtedly had a considerable influence on this response. At the same time, other forces have been prominent in supporting rather different responses, such as strong support for emerging gay groups and programmes directed at male to male sex. While it is easy to point to the sex-negative aspects of official US policy, this too easily ignores the larger cultural, social and political impact of very different influences from within the USA. More important, it becomes an alibi for other governments that show equal distaste for recognising the sexual transmission of HIV, but who largely escape scrutiny because so much hostility is focused on the USA.
From its discovery, through the illnesses of young gay men on the two coasts in 1981, the USA has been central to global developments around the new epidemic, which in many places was originally conceptualised as an ‘American’ disease, such that in Japan and the Philippines gay bars and saunas originally banned westerners as if they carried contamination with them. An American disease perhaps? – but also one associated with globalisation, both in its spread and the responses to the epidemic. HIV was carried across military, trade and tourist routes, and even if the theory that a certain Quebecois air steward was Patient Zero, and somehow the source, an imaginary Adam, of all other infections, is fanciful (Shilts 1987), it took the multitudinous movements of the late twentieth century to ensure HIV quickly reached almost all parts of the world. Whatever the aetiology of the disease it spread quickly, the virus transmitted through sexual intercourse, shared needles and contaminated blood. We sometimes forget that one of the most seriously affected groups were people with haemophilia, many of whom died from HIV in blood that had been donated as a public service by men who were quite unaware of any danger.
The impact of the USA is reflected in both the dominance of biomedical science and the encouragement of political activism. The USA funds and carries out the majority of international biomedical research, and despite the early battle over whether the French discovered HIV ahead of the Americans, US-based researchers have dominated the field (Epstein 1996). Programmes against HIV/AIDS have become the means to spread certain discourses and identities, especially those connected with sex, so that western concepts such as ‘men who have sex with men’ and ‘sex workers’ have become part of the universal language of AIDS. It is important to remember that it was gay organisations across the world, beginning with the Gay Men’s Health Crisis in New York City, that pioneered what would become the most effective mobilisation for prevention, namely peer-based education and information that accepted rather than prohibited a wide range of sexual behaviours and sought to give people the means to reduce the risk of HIV transmission, not change their desires (Altman 1985; Patton 1985).
AIDS is an excellent example of the globalisation of US-based epistemologies: even the dissident views of President Mbeki were fuelled by the US scientist, Peter Duesberg. The international language of the epidemic is largely North American, and its symbols – the red ribbon; the Memorial Quilt; the idea of the involvement of People with AIDS – have grown out of the US domestic response. Indeed, HIV demonstrates Connell’s (2006) argument that the discourses of globalisation are disproportionately those of the North Atlantic. US influence is exerted through a range of institutions, including foundations, universities, pharmaceutical companies, church groups and development organisations, which are often working at apparent cross purposes. Yet in some ways their collective efforts involve an inevitable Americanisation, recalling Joseph Nye’s term ‘coercive democratisation’ (Nye 2006).
US influence on the global pandemic is symbolised by treatment activism inspired by ACT UP, by programmes of monogamy and abstinence, often linked to evangelical Christianity, and by celebrities from Elizabeth Taylor and Richard Gere to Bill Clinton and Bill Gates. One might note the irony that, despite so many signs of US leadership, the major international conferences on AIDS have not been held in that country for 18 years because of the ban, shared with only a few other countries, on admitting people with HIV. This does not mean, of course, that the USA is absent from such meetings. At a planning meeting for the regional AIDS conference held in Sri Lanka in 2006 the names suggested by the local committee for plenary speakers were almost invariably those of people working in the USA; at a similar meeting in Mexico City two years later there were arguments in the programme committee about how far concerns around the US agenda should drive the global debate.
For the first decade of the new pandemic, the USA viewed the epidemic almost entirely through a domestic prism, one which associated the disease with the lifestyle excesses of gay men and drug users. When President Reagan’s Surgeon General, Everett Koop, urged the promotion of condoms and clean needles in his 1986 report to the President, he was denounced by evangelical leaders who objected to any programmes they saw as condoning immorality (Lindsay 2007). HIV/AIDS was mobilised as a rhetorical weapon in attacks on gay rights and, more recently, as a new argument for sexual abstinence, which became an important part of rightwing fundamentalism in the 1990s (Girard 2004). Legislatures have increasingly mandated abstinence as a key part of sex education in schools, with no apparent impact on either the amount of sexual behaviour among teenagers or their rates of pregnancy and STIs. The impact on education is rather akin to that which notions of intelligent design have had on high school biology, with their confusion of ideology with science (Perrotta 2007).
Debate about HIV and AIDS policies, especially attitudes to sex work, abstinence and harm minimisation, has become a lodestone for the larger cultural and political divide in US politics. Expanding access to prevention often means clashes with existing laws and mores and acrimonious debate about sexual behaviours and needle use. Thus the early governmental response in cities such as San Francisco and New York was to close gay bathhouses, rather than, as was true elsewhere, regarding them as sites for prevention intervention. Ironically, more conservative jurisdictions ignored the issue, so that today the most active gay saunas in the USA seem to exist in conservative centres such as Orlando, Dallas and Indianapolis. To cultural conservatives, AIDS appeared the ultimate justification for their attacks on the sexual liberation movements of the 1970s, and morality rather than public health dominated much of the public debate about how best to respond to the new illness.
All religions exercise complex rules and prohibitions around sexuality, and the dominant traditions of monotheistic faiths has been to preach abstinence outside marriage, even while allowing men varying degrees of latitude within marriage. In the USA, the state promotion of abstinence is, however, a feature of the past decade, and a response to a growing hostility to all forms of extramarital sex among certain religious groups. Thus, True Love Waits, an international Christian group focused on teenagers and college students, was created in April 1993 and has organised large-scale rallies and promotions. Pledges to remain virgins until marriage, father/ daughter nights and rallies featuring high-profile celebrities have helped make ‘abstinence’ the most surprising of all sexual movements.
Given the initial responses of the Reagan and Bush administrations, and the fairly timid moves under Clinton, the willingness of George W. Bush to embrace HIV/ AIDS is seemingly surprising. In a front page article in the New York Times at the beginning of his last year in office, Sherry Stolberg suggested that President Bush’s support for international efforts against AIDS might be his ‘most lasting bipartisan achievement’ (Stolberg 2008). Before his selection as Vice Presidential candidate, Senator Jo Biden was quoted as saying Bush’s support for large-scale programmes against AIDS was ‘bold and unexpected, and I believe historians may regard it as his finest hour’ (Kane 2008). In the process of claiming global leadership on AIDS, the USA has also tried to impose a particular brand of sexual morality.
The new disease saw a rapid mobilisation of international responses, first through the World Health Organisation (WHO) then through a new agency, UNAIDS, which expanded on the work of the Global Programme on AIDS within WHO. The USA supported the creation of this new agency, but was not particularly central in the process. As awareness of the scale of the epidemic grew, there was a cautious engagement under Clinton, who has become far more committed to the issue since he left office. Vice President Al Gore and Clinton’s UN Ambassador Richard Holbrooke played a significant role in putting HIV and AIDS on the agenda of the Security Council, which held its first ever debate on a health issue in January 2000. A cynic might note that it was a convenient issue for Al Gore, then beginning his own presidential campaign, as it allowed him to reach out to two important Democratic constituencies, African-American and gay.
The Security Council debate was followed a year later by a special meeting of the United Nations General Assembly, in which the USA under the new president adopted a cautious position on both prevention and treatment access. Indeed, the final statement released by a coalition of most civil society representatives in New York signalled out the Bush Administration for criticism: ‘The United States was particularly damaging to the prospects for a strong declaration. Throughout the negotiations they moved time and again to weaken language on HIV prevention, low-cost drugs and trade agreements and to eliminate commitments on targets for funding and treatment. It’s death by diplomacy, said Eric Sawyer, veteran activist and 25-year survivor of HIV/AIDS’ (Global Network 2006). Specifically, the USA joined with conservative Islamic nations in refusing to name sex workers, men who have sex with men and drug users as particularly at risk. The new Global Fund to Fight AIDS, Tuberculosis and Malaria owed a great deal to advocacy by US academic experts in public health and development, especially Jeffrey Sachs, but it was the UN Secretary General, not the president of the USA, who took the political lead in its establishment, neither was the USA particularly generous in its initial pledges (Davis and Fort 2004).
However, over the coming years President Bush greatly increased bilateral assistance for AIDS programmes, and total US public and private expenditure on AIDS programmes and research now amounts to over half of all global spending on the epidemic. The Gates Foundation is a bigger donor to the Global Fund than countries such as the Netherlands and Australia. Pressure from the original stakeholders, such as gay organisations and some African-Americans, for US involvement was reinforced by the religious right, who developed considerable interest in the issue. The USA has become central in defining new paradigms and responses to the epidemic as the Bush administration has made the issue theirs, and cloaked it with a particular moral agenda.
There is a temptation to attribute too much to overt US influence. Yes, the US government has fostered a set of policies that seemed rather different to the sex-positive attitudes preferred by most community organisations and public health experts. But while it is easy to establish the ways in which this has affected US programmes and funding, it is less clear that these are a dominant factor in accounting for over two decades of denial and neglect in many parts of the world, including countries where there has been no American support for HIV programmes. Note the leap in Elizabeth Pisani’s (2008: 160) recent comment that: ‘We created the “HIV is a development” mantra because neither African leaders nor the international public health establishment wanted to talk about sex in Africa. It became the cement in Kofi Annan’s wall of silence. We’ve exported that cement to countries where leaders don’t want to talk about drug injection, or commercial sex, or anal sex.’ Her last sentence seems to deny the central role of national leaders that is pointed to in the first sentence: how could ‘we’ export a ‘cement’ that was already in place?
Much of the rest of the world took its cues about the new epidemic from the USA, but developed responses that built on local cultural, social and political factors. Thus Sweden also closed its gay saunas in the early stages of the epidemic and has since criminalised the purchasing of sex (although with a feminist justification), while across the Oresund Denmark accepted that sex venues were better seen as opportunities to reach people at risk of infection. Few other western countries adopted US ideologies of sexual abstinence or refusal to recognise gay organisations. Indeed, in much of the western world the mobilisation of gay communities around the epidemic provided a source of government funding and recognition (Altman 1988, 2001).
In other parts of the world the response was far patchier, Thailand, partly due to pressures from the charismatic Meechai Viravaidya and his Population and Community Development Association, developed the 100 per cent condom programme, aimed not at ending sex work but at ensuring all commercial sex involved the use of condoms. While that programme has been criticised by a number of sex worker activists, it did accept the impossibility of preventing commercial sex, and made the promotion of condoms widespread in Thailand. In Uganda, there was an emphasis on zero grazing, namely the reduction of sexual partners plus use of condoms (Epstein 2007). Above all, in Brazil, which stands out as the model response in most areas among all middle income countries, there was extensive support for peer education and empowerment programmes among people whose sexual behaviour made them most vulnerable to infection, namely homosexual men and sex workers.
But for most of this history of the epidemic these were exceptions, and Brazil, Thailand, Uganda, sometimes with the addition of Senegal and Cambodia, became endlessly cited as examples of effective prevention programmes. (Except for Brazil, there was a real failure in these ‘model’ countries to recognise needle users and same sex attracted men in targeted prevention efforts.) In most of the world sex was ignored, and the denial of sexual reality for which the USA is so often blamed was based more on local religious and cultural prohibitions than on any efforts by US officials.
Uganda is the most interesting example, because during the past few years there has been a move away from the original emphasis on zero grazing to a stress on abstinence and monogamy. It is easy to attribute this to the influence of US evangelism, but this would deny the role of Ugandan church and political leaders, who have been very shrewd in lobbying the government to win support for programmes that are as much a product of local as of imported moralism.1 It is an easy resort to neo-colonial analysis to simply attribute the campaign against condom use, and the denunciation of homosexuality and pornography to US money and influence. Clearly Uganda was particularly susceptible to born-again Christian revivalism, but equally African fundamentalism is also impacting on American Christianity, most clearly in the very bitter splits within the Anglican/Episcopalian Church worldwide, where the USA has been far more progressive on issues such as women and gay priests than their African counterparts. Globalisation is not simply a matter of transferring ideas from the rich world to the poor.
Precisely because HIV prevention involves personal behaviours that are often heavily stigmatised and regulated in the name of religion, tradition and morality, it becomes a major arena for clashes. No one opposes access to treatments in the name of religion, but demands that HIV programmes empower sex workers or homosexual men are guaranteed to provoke opposition. A regional UN-sponsored workshop on homosexuality and AIDS in New Delhi in 2006 had to be identified as being on male sexual health to avoid these sensitivities, and most African governments continue to foster the myth that homosexuality is intrinsically ‘non-African’. It is not US pressure that maintains antiquated UK laws criminalizing homosexuality in a majority of former colonies, even though all public health evidence suggests they increase the difficulties of doing effective sexual health promotion. Academic attention to rising religiosity rarely reflects on how this may impact on HIV and AIDS, although both Catholic and Islamic opposition to condoms is a critical factor.
Even allowing for the stated precepts of PEPFAR, the overall impact of the USA globally has been to increased awareness of and willingness to discuss sexuality. The impact of US film and television has been to open up once taboo topics, in ways that anyone who has travelled will recognise. From my early experience of being told by a young Malaysian that he knew all about AIDS from the US telemovie, An Early Frost, through to watching episodes of Sex and the City in Zagreb and Will and Grace in Johannesburg, I have been made aware of the extent to which the global imaginary reflects certain American views, in which the dominant portrayal of sex is far removed from that extolled by the abstinence movement.
The Christian right are strong proponents of a free market economy, and despite crusades against pornography it is difficult for them to square their religious views with the realities that sexuality fuels much of American advertising and consumerism. The moralities that the USA exports are as much those of Wisteria Lane in Desperate Housewives and Beverley Hills 90210 as they are those of fundamentalist churches and abstinence movements.
Despite the apparent influence of the religious right in AIDS programming, there is an evolving US response that combines both a moral and a scientific vision, summed up in the move towards what is called ‘prevention science’. Recent international discourses on HIV prevention stress the idea of combining biomedical techniques with behavioural changes, but the language usually employed is remarkably free from references to sexual pleasure, adventure or experimentation (Pebody and Cairns 2008).
This is a vision that places less emphasis on empowerment and social activism, more on developing new technologies of prevention that both enshrine expertise and seemingly avoid complex moral issues. In 2007 apparent evidence that male circumcision slowed the rate of HIV infections was seized on by a coalition of scientists and international bodies to argue that this practice should be central to HIV prevention efforts. Those who suggested there were complex social and cultural forces that would make this ineffective and possibly dangerous (because it would encourage men to ignore condoms) were brushed aside. The possibility of reconciling science and religious moralism is now the dominant motif of many international HIV policies, and from outside the USA there is a common project of ‘Americanising’ the epidemic that unites apparently very different approaches.
During the past decade there has been a growing emphasis on biomedical interventions as a means of prevention (e.g. microbicides; male circumcision; vaccine development), resulting in concerns that the emphasis on biomedical expertise is at the expense of community mobilisation and empowerment. Too narrow an emphasis on the technologies of prevention leads to the problems identified by an unnamed source from Guyana: ‘Priority prevention issues for the international consultancy firms which dominate the HIV/AIDS programmes in Guyana are not the national issues noted above [i.e. poverty and sexual violence], but the global technical prevention factors of condoms, testing and safe blood. Domestic actors have failed to resist imported formulae or even to articulate an alternative path’ (personal communication).
There is a paradox in the AIDS world, where there are simultaneous pressures for empowering those most directly affected and for increasing biomedical control of prevention programmes rather than seeing them as community owned and directed. The radical vision of much early HIV and AIDS work, which reflected the ‘health for all’ movement that was articulated in the Alma Ata Declaration of 1978, seems increasingly imperilled (Epstein and Kim 2007). At the same time much of the international discourse on HIV has stressed the involvement of those affected and infected, and there have been attempts to assure this, including a strong ‘community’ presence on the board of the Global Fund and the inclusion of affected communities in delegations to UNGASS meetings. This creates demands for programmes to be participatory and community owned, but also ongoing debate whether apparent gains for representation and accountability disguise the creation of a new industry of professional experts (Scalway 2003).
There is some evidence that the US view of the epidemic is becoming more dominant in international discourses around HIV than was the case in earlier periods. Thus, a major session on prevention at the 2008 International Conference on AIDS, organised by the Lancet, included three speakers from the USA but none from Asia or Africa. This is clearest in opposition to sex work, where activists allege that UNAIDS has moved significantly closer to the official US position that equates all cases of prostitution to sex trafficking, and therefore denies the possibility of sex work as something in which people might choose to engage (NSWP Coordinated Response to UNAIDS Draft Guidance on Sex Work 2008).
But US attitudes have shifted as well, and there is tacit support from officials for programmes reaching homosexual men and supporting various harm reduction initiatives for drug users. What unites much of this approach is an emphasis on topdown expertise, and a colonisation of prevention by experts based in biomedicine. This is exemplified in a report from the International AIDS Vaccine Initiative, where prevention is defined almost entirely in biomedical terms (vaccine trials; preexposure prophylaxis; male circumcision; microbicides) with little attention paid to community education and ‘safer sex’ programmes (McEnery 2008).
Under the Obama administration there is, perhaps, likely to be somewhat less emphasis on religious ideology, more on scientific expertise. But the lessons of successful grassroots programmes that linked HIV prevention to empowerment and community norms seem to be forgotten in the rush to link biomedical research more tightly to prevention. The moralities that are being exported still reflect an emphasis on individual rather than social behaviour, but increasingly use the language of science rather than religion. What both approaches share is a reluctance to speak openly of sex, which becomes remarkably invisible in the new language of prevention technologies. When AIDS first emerged as a political issue quarter of a century ago, it was widely seen as requiring a new openness and awareness of the varieties of human sexuality. The combined pressures of moralism and biomedicine risk denying the eroticism and pleasures of sex in favour of an emphasis on risk and danger.
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