||Issue Date: 4 / 2005
Uganda Draws Back From the AIDS Brink
Chris Baryomunsi, A. B. T. Byaruhanga-Akiiki, and Robert S. Kittel
Dr. Bolingo Tiba sat huddled alone on the floor in a bare room lost in Bukoto, one of Kampala's sprawling residential areas. Not three years before, his busy clinic had been a magnet for the city's impoverished and sickly masses, especially those who suffered the scourge of AIDS. Tiba always had kind words, a gentle touch, and whatever medicines he could acquire to make their lives slightly less burdensome.
Hillary Clinton speaks to students at Makerere University in
Kampala, the capital of Uganda, in 1998. The country has
international attention due to its dramatic slowing of HIV
transmission. (Sharon Farmer / White House / UPI)
That all changed one day when, after helping so many people, he found himself HIV positive. Although he spent a lot of money trying to rule out the infection, it was to no avail. He definitely had the virus. When his family and friends learned of his condition, they abandoned him, except for one brother.
The once bright, energetic, and well-liked doctor became an outcast--socially isolated, rejected, and avoided. A number of his relatives planned to kick him out of his own house and started looting his things. To them, his diagnosis meant he was already dead and should not have any property. Many feared that by associating with him, they might contract the disease.
His former friends became very distant and stopped visiting; of course, he could not visit them. His wife ran away after she managed to grab the will. Angry and resentful, thinking her husband might have infected her, she was nonetheless afraid to get screened.
Tiba lost all interest in life. He was emotionally empty and dry, with such an indescribable loneliness in his heart that he began to think of committing suicide.
Although Tiba is not the doctor's real name, the details of the story are true, reflecting the conditions in Uganda during the early years of its battle with AIDS. As the country's incidence of HIV/AIDS soared in the late 1980s and early nineties, the people collectively fell into a downward spiral, just as Tiba was caught in his own death spiral.
Today, Ugandans can look back toward the brink of chaos on which their country had teetered and marvel. Uganda has stepped away from the deadly edge by marshaling its full resources--social, economic, political, spiritual, and religious--to join the battle against HIV/AIDS.
"Uganda," according to a 2003 report from the U.S. Agency for International Development (USAID), "has experienced the most significant decline in HIV prevalence of any country in the world." With the HIV/AIDS pandemic still raging out of control in dozens of countries, it is urgent that we learn lessons from Uganda's story. These lessons promise success to other nations in their fight against HIV/AIDS and other sexual diseases. Uganda's story of honesty and integrity, faith and good governance attests clearly to the powers unleashed when government and faith-based organizations join forces toward a common, righteous goal.
Of the over forty million people living with HIV/AIDS worldwide, nearly 75 percent live in sub-Saharan Africa, whose population is only about 10 percent of the world's inhabitants. Among the twenty million people who have died of AIDS, fourteen million have been Africans.
In the mid-1980s, Uganda and Tanzania shared the macabre distinction of being the two countries in the world with the most reported cases of AIDS. The first case in Uganda was discovered in 1982, in the southwest district of Rakai bordering Lake Victoria.
The mysterious disease, then known as slims, infected seventeen fishermen at Kasensero Landing Site. However, due to continued civil strife, the silent epidemic went largely unnoticed until 1986 when the country's new president, Yoweri Kaguta Museveni, sent sixty of his elite soldiers to Cuba for training. In September, Cuban President Fidel Castro informed the Ugandan president that eighteen of the soldiers had tested positive for the human immunodeficiency virus.
By the late 1980s, the picture in Uganda could hardly have appeared more bleaktwo-thirds of female prostitutes, two-thirds of barmaids, one-third of truck drivers, one-third of male blood donors, and one-sixth of female blood donors in Uganda were HIV positive. In some districts, nearly one-third of pregnant women visiting clinics were infected with HIV.
Although Uganda had awakened to a nightmare, Museveni's decisive actions confronted the nightmare head-on and overcame it. In the first decade of his administration, the president implemented a low-cost, indigenous, and effective response. As a result, nationwide HIV seroprevalence rates decreased from 22 percent in 1991 to 6 percent in 1999.
A "good" disease
Uganda's success in reversing the rising tide of HIV/AIDS has attracted widespread attention and serious evaluation. Several studies identify Museveni's direct, public, and morality-based involvement with fighting the disease as pivotal. Not only did he make fighting the HIV/AIDS pandemic a personal priority by himself carrying the message to all of Uganda's fifty-six political districts, he also brought the national department of HIV/AIDS abatement into his executive office, involving leaders from many sectors of society and government departments in the project.
"An optimist in the midst of despair" characterizes Museveni's attitude toward the AIDS crisis. In a speech titled "AIDS: The Greatest Leadership Challenge," the Ugandan president described the deadly virus as a "good disease." Unlike other diseases that are airborne or transmitted through casual skin-to-skin contact, AIDS is good "because it is, largely, an infection of choice. It is a largely sexually transmitted disease and can, therefore, be avoided through proper sexual behavior." Facing a Herculean challenge, Museveni broke conventions of thought and habit that have long characterized the governance model of Western-style democracy.
He spoke openly about sexual behavior while upholding abstinence and fidelity as both morally preferable and pragmatic in the face of the threat of AIDS. Going a step further beyond convention, Museveni fostered substantial collaboration among religious groups, secular groups, and government.
With decentralized planning, Uganda's anti-AIDS alliance reached general populations as well as key target groups with messages for women and youth, including, for those already infected, discussions on stigma and discrimination.
A remarkable collaboration
As good and important as the elements mentioned above are, in and of themselves they do not lower HIV prevalence rates. This is because, according to a United Nations report, "in sub-Saharan Africa, the main mode of transmission [of HIV/AIDS] is heterosexual sex." A U.S. government report titled What Happened in Uganda? concludes that "Uganda's response, such as high-level political support, decentralized planning, and multi-sectoral responses, do not affect HIV infection rates directly. Sexual behavior itself must change in order for seroincidence to change." Two types of sexual behavior changes have been identified. These are described by Edward C. Green of the Harvard Center for Population and Development Studies, writing in the USAID booklet Faith-Based Organizations: Contributions to HIV Prevention. In the first type of sexual behavior change, called risk reduction, a sexually active man who has multiple sexual partners and has never used any protection begins to wear a condom. By so doing, he has changed his behavior in a way that reduces his and his partners' risk of transmission. But he has not altered his risky behavior; that is, he has not reduced the number of sexual partners or shown any measure of sexual self-control.
The other behavioral change, called risk elimination, is considered more fundamental because it involves either abstaining from sexual activity for a time or decreasing the number of sexual partners. The University of London's John Richens has proposed the term "primary behavioral change" for the second type.
Uganda's success shows that both types of change are important in fighting AIDS. A report from USAID states that "changes in age of sexual debut, casual and commercial sex trends, partner reduction, and condom use all appear to have played key roles in the continuing declines [of HIV infection rates]." The Ugandan president also acknowledges that condom usage has played a partial role.
At the African Development Forum 2000 in Addis Ababa sponsored by the United Nations Economic Commission for Africa, he noted that "condom use increased from 57.6 percent in 1995 to 76 percent in 1998." But condom distribution was closely regulated within a unique set of priorities known as the ABCs of HIV/AIDS prevention.
The ABC model
Uganda's ABC model emphasizes three dimensions of sexual behavior: Abstinence, Be faithful (fidelty), and Condoms (used correctly and consistently). The model has recently been adopted by USAID. Here A and B relate to risk elimination or primary behavioral change, while C corresponds to risk reduction.
In the Ugandan collaboration of government, faith-based service organizations, and secular service organizations, the greatest controversy has revolved around the model's C portions.
The lesson from Uganda is that finding a way to handle this part of the program while keeping all parties involved is essential to achieving success.
The USAID booklet by Green states that "a conflict remains in many countries between taking a medical or 'realistic' approach to AIDS prevention . . . and taking a religious or 'moral' approach. The popular press and some AIDS literature pit medically enlightened progressives who recognize human behavior as it actually is against religious conservatives who moralize about how behavior ought to be. The former emphasize condom use and the treatment of sexually transmitted infections, whereas the latter emphasize abstinence and fidelity." Museveni's strategy emphasized A and B (abstinence and be faithful), while it also allowed condom distribution under the Ministry of Health's AIDS Control Program as early as 1986. The social marketing of condoms beyond the health sector, however, didn't begin until 1991. Even then the marketing effort maintained a low public profile, a policy the government termed "silent promotion." With its limited promotion of condoms, Uganda's AIDS prevention policy was clearly centered on primary behavioral change, without eliminating the safety net. Evidence from many sources indicated that the lion's share of Uganda's success can be attributed to the A and B portions of the model.
In April 2004, the government-owned Vision newspaper quoted Museveni as affirming that "it is behavioral change and not condom use that has led to the reduction of HIV infection." He later emphasized several points: first, that promiscuity was the main reason for the spread of AIDS and so students at the appropriate age should be encouraged to seek "a partner and start a lifetime relationship"; second, that when he proposed the use and distribution of condoms, he wanted them to remain in the urban populations "for the prostitutes to save their lives"; and third, that beyond not agreeing with "the [liberal] teaching of the Western countries on the use of condoms," he condemned their "distribution . . . to primary school pupils . . . [as] dangerous and disastrous."
A broad consensus
Undoubtedly, Uganda succeeded because the president encouraged a "broad consensus ... [of] players in both government and civil society" to tackle the HIV/AIDS problem. Specifically, it was an alliance between political and religious institutions that evolved as he sought the most effective way to deal with a national emergency.
In retrospect, it is clear that a crucial step in that evolution was putting the Uganda AIDS Commission (UAC) directly under the Office of the President. As an interministerial agency, the commission could require cooperation among many government ministries in order to create and implement an effective AIDS policy. By providing direct oversight, it sent the signal throughout the government and nation that AIDS was a presidential concern.
One additional factor proved essential for reaching out to faith-based organizations (FBOs). After creating the UAC, Museveni chaired its first meetings, but then he appointed a religious leader, the late Bishop (Anglican) Misaeri Kawuma, as chairman.
This act fostered tremendous goodwill between the government and the religious communities, which constitute the strongest and largest nongovernmental organizations in Uganda. It placed the religious voice on par with select ministerial appointments and created a full interreligious-intergovernmental partnership. The collaboration of these two sectors of society changed the course of a nation.
The potentially divisive C policy was delicately handled as both a moral and a health issue. If condoms were banned, the health community would be up in arms. If condoms were promoted as the primary solution to AIDS, FBOs would likely be alienated.
Museveni's policy allowed health professionals and religious leaders to sit at the same table. Key strategies disarmed the potential controversy:
Religious leaders were not asked to jeopardize their theologies.
Limited condom distribution, as a health concern, continued quietly under the Ministry of Health.
Sexual abstinence and marital fidelity were emphasized as the primary solution to HIV/AIDS and stressed publicly.
When the social marketing of condoms was permitted, it specifically targeted commercial sex traffickers.
A simple, uncompromising message
Speaking in Washington, D.C., in June 2004, the first lady of Uganda, H.E. Janet Museveni, explained why the message of abstinence and fidelity was effective.
First, the message was "simple and uncompromising." It consisted of three parts: HIV is transmitted through sexual relationships; it can be avoided through controlling sexual behavior; and, if contracted, AIDS will kill its victim, since the disease is incurable.
Second, the message from political leadership was multiplied a thousandfold by each citizen taking responsibility.
A third factor was the negative precondition that every Ugandan family or neighbor was personally affected by "the horror of death."
The fourth factor, a positive precondition, was the country's heritage of moral values and religious institutions. Traditionally, sexual purity was required among young unmarried women. Both the Christian and Muslim faiths attach great importance to strict moral conduct among the young.
Mrs. Museveni went on to say that despite the "disruptive effect" of civil unrest and foreign influence, the moral values of Ugandan youth remained strong and were the basis upon which "to inculcate a culture of discipline and self-control in our young people." She emphasized the pivotal role played by the diverse FBOs that have gained the trust of many types of people through their religiously motivated service.
In essence, Uganda succeeded because the church and mosque worked cooperatively with the state; the religious community became a full partner in governing and implementation.
But Uganda did not become a theocracy, and the 85 percent Christian population did not trample the rights of the Muslim minority. Working together, Uganda's government and the FBOs did what no other country on earth could then do: They tackled the evil of HIV/AIDS--the ignorance, the stigmatization, the innocent victims, the fractured families--giving hope to the helpless.
Thanks to its distinctive heritage, Uganda seems to have been especially well prepared to pioneer this approach to solving a national problem. Its motto, "For God and My Country," foreshadows and frames Uganda's conjugation of the secular and the sacred. The fight against AIDS was not only a patriotic duty; for many, it was also a religious obligation.
Uganda, called "The Pearl of Africa" by Sir Winston Churchill, has lived up to its name, giving the world a precious gem of wisdom in the fight against HIV/AIDS: an indigenous, cost-effective model that works. The challenge for the rest of us is to see the way that model can be adapted in different countries and cultures to unleash the hidden potential of political-religious collaboration.
Future generations will surely thank those who do.
© 2005 World & I: Innovative Approaches to Peace
Chris Baryomunsi, a medical doctor, demographer, and public
health specialist, is a technical adviser on HIV/AIDS for the
Ugandan Office of the United Nations Population Fund. A.B.T.
Byaruhanga-Akiiki is professor of comparative religion,
ecumenism, and culture at Makerere University in Kampala,
Uganda. Robert S. Kittel, assistant secretary-general for the
Interreligious and International Federation for World Peace,
cofounded and for eight years codirected the Pure Love
Alliance, a youth-based, abstinence-until-marriage program.