Engaging Conservative Activists
Twenty years into one of the worst health
disasters in human history, the AIDS pandemic continues to grow
exponentially, outstripping prevention efforts and treatment
programs; every day it kills 8,000 people and infects 13,700 more.
Although the United States provides fully half the foreign aid aimed
at the pandemic, the total has been woefully inadequate to check its
spread or stop the deaths -- until now.
Thanks to recent activism by conservative
political and religious groups, AIDS has finally started to gain
foreign policy attention commensurate with its substantive
importance. Prodded by its conservative evangelical base, the Bush
administration has pushed AIDS to the forefront of its international
agenda, backing record increases in U.S. assistance for AIDS
treatment abroad and beginning to address issues such as sex
trafficking and the dangers of HIV transmission from unsafe
injections and blood transfusions.
The future of U.S. global AIDS policy will be
complicated, however, because the conservative groups interested in
the issue have different tactical priorities than their liberal
counterparts and the broader medical establishment. They have
traditionally been hostile to some important AIDS-prevention
strategies such as comprehensive sex education and condom
distribution, and they are much more enthusiastic than others about
policies such as the promotion of abstinence.
Now that the United States is finally
stepping up its efforts to tackle the crisis, it would be tragic if
their impact were dissipated because of ideological differences
between constituencies that are vital to the struggle against AIDS.
The time has come, therefore, for all interested in AIDS policy to
unite behind a comprehensive strategy to combat the pandemic, one
based on the most effective practices in both prevention and
treatment. The tens, possibly hundreds, of millions at risk deserve
no less.
Until recently, almost all foreign-funded
AIDS programs in Africa, Asia, and Latin America have been directed
toward prevention. Whatever justifications there might be for a
prevention-only approach to the pandemic, the strategy has proved
neither morally nor medically sustainable.
Ignoring AIDS treatment is tantamount to
condemning to death the more than 30 million Africans, most of them
in the prime of their lives, who have the disease. Moreover, an
estimated 95 percent of Africans do not know their HIV status,
partly because the stigma associated with AIDS discourages them from
participating in counseling and testing programs. A better-informed
population could move more effectively to control the spread of the
disease, but absent the possibility of treatment, people have little
incentive to learn whether they have the virus or not.
Jim Kim, a senior official at the World
Health Organization (WHO) and one of the world's leading AIDS
experts, has noted that making treatment available would actually
help prevention. He testified before the U.S. Senate that even in
Uganda, where prevention efforts have been among the most successful
in Africa, prevalence seems resistant to reduction below eight
percent when preventive approaches are used alone. Along with most
other infectious disease experts, therefore, he advocates
comprehensive programs that integrate prevention and treatment into
a mutually supporting package.
Yet seven years after the development of the
"cocktail" of drugs now widely used to treat AIDS in the West, fewer
than one percent of sub-Saharan Africans and five percent of Asians
who need it have access to it. The single most important impediment
to universal treatment is the exorbitantly high cost of the
medication. Pressure from AIDS activists has driven down the price
of treatment from thousands to hundreds of dollars annually. Yet
even at these prices generic drugs remain well out of reach for the
poor in the developing world; extensive foreign aid for treatment
programs is therefore essential.
In 2001, accordingly, UN Secretary-General
Kofi Annan announced the creation of the Global Fund to fight AIDS
and other infectious diseases and asked wealthy donor nations for $7
billion to $10 billion a year. In June that year the UN General
Assembly met in special session and endorsed a comprehensive
approach to disease management, including integrated prevention,
care, and treatment. President Bush pledged $200 million to Annan's
fund and boosted bilateral assistance efforts, but U.S. funding for
foreign AIDS programs still hovered at less than a fifth of what
activists considered an appropriate share of the global burden.
After that, support for treatment for people with AIDS in the
world's poorest countries gradually increased in Congress and among
nongovernmental organizations. But the real turning point in
American AIDS policy came when conservative Christians made the
cause their own.
In February 2002, Franklin Graham, son of
Billy Graham and founder of Samaritan's Purse, an evangelical
charity based in South Carolina, convened the first "international
Christian conference on HIV/AIDS." More than 800 evangelical
Protestant and Catholic leaders and overseas missionaries from
AIDS-stricken countries gathered in Washington, D.C., for the
meeting, titled "Prescription for Hope," and demanded treatment for
the sick and the dying. Graham's superstar status among evangelicals
and the conference's state-of-the-art visuals, gospel choruses, and
heartbreaking testimony from African ministers and health workers
convinced American religious conservatives that it was their moral
duty to do something about the pandemic.
The highlight of the conference came when
81-year-old Senator Jesse Helms (R-N.C.) stated, "I'm so ashamed
that I have done so little" to help the victims of AIDS in Africa.
Within days, the senator published an op-ed in The Washington Post
promising to secure $500 million to prevent mother-to-child
transmission of the disease. By focusing on the "innocent victims"
of AIDS, Helms publicized the fact that in Africa the disease was
usually transmitted heterosexually, reaching audiences who had
previously disregarded its spread among homosexuals or considered it
a God-sent punishment.
President Bush went on to make a dramatic
commitment to tackling the pandemic in his 2003 State of the Union
address. In a speech designed to prepare the world for war in Iraq,
the president announced an "Emergency Plan for AIDS Relief" and
committed $15 billion over five years to the cause. The plan
promised to provide treatment for two million people and enough
support to prevent seven million new HIV transmissions in Africa and
the Caribbean. Although scale-up of this program has been slow, the
conservatives' endorsement of the president's intention to put
millions of people on anti-retroviral therapy has settled the
controversy over treatment once and for all.
Conservatives have also provided welcome
leadership in helping reduce the transmission of HIV/AIDS through
unsafe needles and blood transfusions. According to the WHO, unsafe
health care accounts for at least 500,000 new AIDS transmissions
every year and possibly many more. Yet reducing this number has not
been a priority for the international health establishment, which
considers such numbers trivial compared to the number of people
infected through heterosexual intercourse. But a leading Senate
conservative, Republican Jeff Sessions of Alabama, has taken this
issue to heart.
When a new study was published in early 2003
suggesting that transmissions from unsafe health care could
represent far more than seven to ten percent of new cases, as the
WHO estimates, The Washington Times covered the story, conservative
groups picked it up, and Sessions held two Senate hearings on it.
Some AIDS activists feared that religious conservatives would use
the issue to discredit and undermine prevention efforts and justify
diverting funds from condom distribution and reproductive health
programs. But Sessions' safe health care initiative proved them
wrong. While calling for new studies to clarify the source of AIDS
transmission, Sessions neither refuted the role of sexual
transmission in the pandemic nor criticized safe-sex programs. By
the end of 2003 he had built bipartisan support for mainstreaming
the issue of injection and blood safety into U.S.-funded prevention
strategies, reversing decades of neglect and offering considerable
support for building proper health infrastructure in the poorest
countries in Africa.
Conservatives in the House of
Representatives, meanwhile, have highlighted another neglected but
significant source of AIDS transmission: the violent sexual
exploitation of trafficked women and children. The issue is hardly
minor: the State Department estimates that India alone has 2.3
million women and underage girls forced into its sex industry, and
in Africa AIDS is fueling an epidemic of sexual predation against
ever-younger girls as older men seek safe sexual partners. The
pandemic is also generating millions of orphans and street children
throughout the developing world who are especially vulnerable to
rape and to being forced into the commercial sex industry.
Forcibly prostituted women and sexually
exploited children are not "sex workers" but victims of crimes,
including multiple rapes daily. They are particularly vulnerable to
AIDS transmission, but their needs are not addressed by conventional
prevention programs, which are designed for voluntary sex workers
and stress empowerment, health care, and access to condoms. Reducing
harm for trafficking victims involves not encouraging safer sex but
removing them from the sex industry and providing them with shelter,
rehabilitation, counseling, and health care. The predators who
sustain the forced-sex trade and child rape industry, meanwhile --
the traffickers, brothel owners, and complicit police and other
authorities -- should be punished severely, with significant jail
time.
Yet this almost never occurs, and most
trafficked women and children languish in sexual servitude with no
hope of release. Many who provide health services to sex workers
acquiesce in the forced exploitation of children and women in the
brothels where they work because they are unwilling to jeopardize
their access by reporting pimps and brothel owners. Several of the
most prominent service providers in Thailand, for example, actively
oppose rescue and rehabilitation, and some rehabilitation facilities
in India refuse to accept child prostitutes who have been
rescued.
Hoping to discourage trafficking,
Representative Chris Smith (R-N.J.), a conservative Catholic and an
anti-trafficking leader in the House, offered a provision to the
AIDS bill that prohibited funding to any organization that did not
oppose trafficking and prostitution more generally. According to one
of Smith's aides, the measure was aimed at service provider groups
who were "a little too casual about Sway Pak" -- a notorious
redlight district in the Cambodian capital of Phnom Penh that offers
very young Vietnamese girls to Western customers. Smith and
like-minded religious conservatives are appalled by trafficking and
child prostitution and by the notion that prostitution can be a
voluntary choice. Their view -- which is hardly limited to the
extreme right -- is that prostitution is always a compelled choice,
through either violence or destitution, and that glamorizing it as
"work" trivializes the harm it does to the women in it.
It is certainly the case that many in the
commercial sex industry, whether trafficked or not, wish to leave it
and would do so if alternative employment were available. A 1998
survey of sex workers in Turkey, the United States, Zambia, South
Africa, and Thailand, for example, indicated that a large majority
of them suffered physical and sexual violence and post-traumatic
stress disorder and that almost all wished to leave the business.
Sexually exploited Ethiopian street children interviewed by Save the
Children overwhelmingly disliked prostitution and wished to escape
it. All sex workers are at very high risk of AIDS exposure, but
children and trafficked women are especially vulnerable, as their
ability to negotiate condom use with clients is virtually
nonexistent.
Rather than pitting the interests of victims
of forced prostitution against those of voluntary sex workers, two
distinct strategies to fight AIDS transmission should be developed.
Rescue initiatives, shelters, and alternative job opportunities, as
well as reform of the police and the judiciary, should be funded to
help those who wish to leave brothels. Health care, protection from
violence, and freedom to organize should be promoted for those who
wish to stay in the trade. Documenting and exposing sexual
exploitation is essential, but an ombudsman or specially trained
antitrafficking unit is better suited to the task than health
workers attempting to disseminate condoms in brothels.
To date, the programs that have most
successfully addressed the right of sex workers to health care have
been empowerment projects that help sex workers organize around
their own needs, such as the Sonagachi program in Calcutta, India.
Sonagachi is credited with raising condom use in neighborhoods with
organized brothels from less than 1 percent to more than 80 percent,
reducing police violence toward prostitutes, and providing services
for prostitutes' children. It is true that Sonagachi and similar
programs are unabashedly "pro-prostitution" in that they aim to
empower women within the sex trade rather than urge them to leave
it, but Sonagachi's adult women sex workers are also reported to be
vigilant in opposing the presence of children in their brothels.
Despite what people on both sides of the controversy might think,
there is no reason why this sort of effort cannot coexist and
complement well-designed antitrafficking campaigns.
The involvement of conservative groups in
shaping AIDS policy has been most problematic in the area of general
AIDS-prevention strategies, where their distinct sexual mores have
led them to dissent from what most others consider medical best
practice. For example, since condoms, if used properly and
consistently, are at least 90 percent effective in preventing AIDS
transmission, the U.S. Agency for International Development (USAID)
has quietly provided millions of them annually to AIDS-stricken
countries. Now that religious conservatives have taken up the AIDS
cause, however, such programs have come under attack. Thus the
Family Research Council has insisted that the Bush administration's
AIDS plan not become "an airlift for condoms," while conservative
religious groups convened by Senator Sam Brownback (R-Kans.) have
taken aim at various prevention programs that the plan had
considered funding.
By the time legislation implementing the
president's vision -- the United States Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Act of 2003 -- was completed,
conservatives in the House had succeeded in redirecting one-third of
its AIDS-prevention funding toward programs urging abstinence before
marriage. The conservatives are inspired by Uganda's "ABC"
(Abstinence, Be Faithful, and Use Condoms) program, which has helped
lower prevalence dramatically, and are particular fans of its A and
B components, which, if faithfully adopted, might offer nearly total
AIDS protection. As Chuck Colson and William Bennett of the
organization Empower America argued in a recent essay, "African
nations that promoted condom use alone, and which have the highest
condom user rates on the continent ... also suffer the highest HIV
prevalence rates. Clearly, condoms must no longer be considered the
first line of defense against HIV. ..."
Unfortunately, however, scientific evaluation
and medical surveillance paint a different picture. Studies of
Ugandan AIDS prevalence that try to assess the relative
contributions of abstinence, multiple-partner reduction, and condom
use in lowering infection rates have found that abstinence actually
made the smallest contribution, while condoms and partner reduction
had the largest impact. David Serwadda, a Ugandan physician who
chairs the Global HIV Prevention Working Group, has stated, "As a
physician who has been involved in Uganda's response to AIDS for 20
years, I fear that one small part of what led to Uganda's success --
promoting sexual abstinence -- is being overemphasized in policy
debates."
At home, meanwhile, the U.S. government
currently provides $100 million per year for abstinence education,
making the aid conditional on schools' commitment to neither endorse
condoms nor provide instruction on their use. Kenneth L. Connor,
president of the Family Research Council, has suggested extending
such policies to Africa, on the grounds that "responsible moral
behavior is the first and best line of defense against AIDS, and is
the only message we should send young people worldwide."
But here again, researchers who have compared
abstinence-only and comprehensive sex-education programs in the
United States have found little evidence that the former had any
effect on sexual behavior or contraceptive use among sexually active
teenagers. And sexually inactive teens who received comprehensive
sex-education were more likely both to delay sexual initiation and
to use condoms once they did start having sex than their peers who
received abstinence-only instruction.
Another problem with the abstinence approach
is that it fails to single out certain marginalized groups who are
especially at risk of HIV/AIDS infection. Outside southern Africa,
for example, AIDS prevalence is highest among sex workers,
intravenous drug users, and homosexuals. Since these groups suffer
discrimination and persecution within their own countries and are
often denied access to government health and prevention programs,
experts concerned with stopping the spread of the pandemic believe
those groups should be singled out for special attention. Yet USAID
is reportedly now under heavy pressure to scale back or eliminate
outreach, peer counseling, and condom distribution to at-risk
groups. The National Institutes of Health and the Centers for
Disease Control, moreover, are reportedly screening out research
proposals containing the words "homosexual," "prostitute," and "drug
user" in their titles, and whistle blowers within the agencies have
reported pressure to approve scientifically unsound HIV
projects.
The AIDS pandemic is almost incomprehensible
in its enormity, and in most of the developing world it is still in
its early stages. As the world's richest, most powerful, and most
scientifically advanced nation, the United States can and should
play a uniquely active role in combating this scourge.
The entry of religious conservatives into the
struggle has helped galvanize U.S. AIDS policy and has given the
issue a welcome hearing in Congress and the White House. They have
put treatment on the political map, and have focused attention on
certain unjustly neglected issues such as sex trafficking and
transmission through unsafe health care practices. The challenge now
is for all those concerned about AIDS to fight the pandemic on all
fronts, preventing transmission where it occurs and treating all
those in need.
Whatever their views on other issues,
conservatives, liberals, and the medical community should be able to
reach at least a rough consensus on the most effective practices in
both prevention and treatment. The AIDS pandemic will not wait while
one successful prevention program is traded for another or scarce
resources are squandered on unsound approaches. If a common front
can be matched with some common sense, the results could be truly
impressive.
~~~~~~~~
By Holly Burkhalter
Holly Burkhalter is Director of U.S. Policy
and of the Health Action AIDS campaign at Physicians for Human
Rights.