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.
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.
Uganda prevails
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 reducti
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.