Let Africans Decide How to Fight AIDS
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For my Africans colleagues, who do not see the Washington Post,
let me paste my op-ed article written with Dr Mlay here on AFRO-
NETS:
Let Africans Decide How to Fight AIDS
By Edward C. Green and Wilfred Mlay
The Washington Post, Saturday, November 29, 2003; Page A23
http://www.washingtonpost.com/wp-dyn/articles/A20298-2003Nov28.html
As the United States prepares to implement President Bush's
five-year, $15 billion Emergency Plan for AIDS Relief, special
interests on both sides of the social-political spectrum are at-
tempting to export some of the worst of America's prejudices to
Africa. At issue is funding for prevention and, in particular,
the widely debated approach to AIDS prevention known as ABC: Ab-
stain, Be faithful or (for those especially at risk) use a Con-
dom. Under the legislation, 20 percent of the funding -- or $3
billion over five years -- would be used for prevention. How
that money will be spent is the controversial and important is-
sue -- and for many a matter of life or death.
Some U.S. conservatives favour an "abstinence-only" approach,
while many on the other side dismiss abstinence in favour of
condoms. Lost in the debate is the decline in extramarital and
casual sex -- which has proven effective in reducing HIV infec-
tion rates in Uganda, Zambia and elsewhere.
In truth, good public health policy requires A, B and C to re-
verse the AIDS epidemic. But partisans ignore the facts.
Condoms are effective in slowing the spread of AIDS among those
particularly at risk: people with HIV-infected partners, women
trapped in the commercial sex industry, their customers and
those customers' wives. While condoms arguably may have stabi-
lized HIV transmission rates in the United States -- where AIDS
is largely confined to those engaged in high-risk behaviour --
they have proven inadequate in countries where most HIV is found
in the general population.
Those who consider condoms a panacea for Africa's AIDS epidemic
ignore their track record and naively apply a U.S. solution to
an African problem. In fact, the African countries with the
highest levels of condom availability -- Zimbabwe, Botswana,
South Africa and Kenya -- also have some of the highest HIV
rates in the world.
Uganda is a case in point. Between 1991 and 2001, Uganda lowered
its infection rate from 21 percent to 6 percent. Unlike most
heads of state, Uganda's president, Yoweri Museveni, intervened
early and forcefully. Impoverished and war-weary, Uganda adopted
the least expensive intervention available: public education
stressing abstinence before marriage and faithfulness after.
"Zero grazing" -- staying faithful to one partner -- was the
message Museveni and other government officials repeated over
and over. Between 1986 and 1992, the Ugandan ABC model was
mostly focused on A and B, reserving condoms primarily for those
already infected and high-risk groups. Comparing condoms to
penicillin, Museveni said, "Just as we were offered the 'magic
bullet' in the early 1940s, we are now being offered the condom
for 'safe sex.' We are being told that only a thin piece of rub-
ber stands between us and the death of our continent. I feel
that condoms have a role to play as a means of protection, but
they cannot become the main means of stemming the tide of AIDS."
Museveni enlisted Uganda's religious community, which reinforced
the A and B message. While many religious leaders opposed the
use of condoms, they remained relatively silent on the issue to
avoid undermining public health efforts. The approach worked.
The number of young people engaged in premarital sex plummeted
between 1989 and 1995. By 1995, according to a survey financed
by the United States, 95 percent of Ugandans were reporting ei-
ther one sexual partner or none. Most Ugandans in the ages sur-
veyed, 15 to 49, are married and therefore sexually active, so
"zero grazing" was the predominant response to the threat of
AIDS.
Moreover, in countries where infection rates exceed 30 percent
and funerals for family and friends are held several times a
week, abstinence and faithfulness are attractive alternatives to
death. This central fact is often lost in the U.S. debate over
abstinence vs. condoms.
The Ugandan turnaround was well underway by the time foreign
AIDS experts began to arrive in the early '90s, bringing with
them Western public health approaches -- and values. They began
to retool Uganda's AIDS prevention efforts away from abstinence
and fidelity -- goals that many Westerners felt were unrealis-
tic. As condom use increased, the percentage of young singles
having sex rose from 27 percent to 37 percent between 1995 and
2000. Health officials worry that infection rates may increase
as well.
Africa is finding its own solutions. In particular, its faith
community -- which in many countries already provides most of
the care and comfort for the sick and dying as well as the or-
phans and vulnerable children -- has a significant role to play
in contextualizing and implementing Bush's plan.
The United States should be applauded for its generous invest-
ment in the fight against AIDS. But this historic opportunity --
not to mention billions of dollars and the lives of countless
men, women and children -- will be wasted if ideology trumps
proven public health policy. American partisans must not be al-
lowed to make decisions from thousands of miles away -- and from
a culture even more distant -- on ways African couples protect
themselves from this most intimate of diseases.
--
Edward Green, a medical anthropologist with 25 years of experi-
ence in Africa, is a senior researcher at the Harvard School of
Public Health. His latest book is "Rethinking AIDS Prevention."
Wilfred Mlay is World Vision's vice president for Africa and a
former professor and academic dean at the University of Dar-es-
Salaam in Tanzania.
[Please be cautioned against ordering "Rethinking AIDS Preven-
tion" from Amazon.com. They are charging US$ 69 whereas the real
price is US$ 39.95, plus Amazon is telling people that the book
will not be out until Feb. 2004, whereas it is already avail-
able. Best to order it from:
http://www.greenwood.com/books/BookDetail.asp?dept_id=1&sku=T316&imprintID=
Rethinking AIDS Prevention
Learning from Successes in Developing Countries
Praeger Publishers - ISBN: 0-86569-316-1; 392 pages
List Price: US$ 39.95; UK Sterling Price £25.80
Edward Green
mailto:EGreendc@aol.com