While most discussion of President George W. Bush’s foreign policy centers around the much maligned invasion of Iraq, the ongoing conflict in Afghanistan, and the escalating tension with Iran, only slight attention is usually given by the media and the public to this administration’s policies in Africa concerning the HIV/AIDS crisis. Bush, in fact, is responsible for a “dramatic increase in U.S. aid to Africa,” boosting “direct development and humanitarian aid… to more than $4 billion a year from $1.4 billion in 2001,” thanks to the passage of the AIDS Leadership Act in 2003. Behind these impressive numbers, though, are underlying issues that have outraged some international health and aid organizations, invigorating a debate over how aid should be distributed and what the priorities should be. One of the most controversial clauses in the AIDS Leadership Act states that federal funding is unavailable “to any group or organization that does not have a policy explicitly opposing prostitution and sex trafficking.” Stipulations like this one, which is currently the subject of ongoing litigation, have served to undermine the potential of foreign aid to curb the epidemic of HIV/AIDS in Africa.
During his State of the Union address in 2003, Bush proposed the AIDS Leadership Act, claiming that “this comprehensive plan will prevent 7 million new AIDS infections, treat at least 2 million people with life-extending drugs and provide humane care for millions of people suffering from AIDS and for children orphaned by AIDS.” He touted the success of this five-year, $15 billion initiative in his 2007 State of the Union speech when he said that “the number of people receiving life-saving drugs has grown from 50,000 to more than 800,000 in three short years.” Many are unaware that these efforts were largely spurred by Bush’s “Christian supporters [, who] seldom get the credit they deserve for their role in the global fight against AIDS.” While there has been discernable progress stemming from Bush’s policies, there has also been serious criticism that moralistic provisions within the policy have hampered aid organizations and have cost countless lives.
The manner in which wealthy countries like the United States contribute foreign aid has drawn disapproval from those saying that the amount is too little and is “primarily designed to serve the strategic and economic interests of the donor countries or to benefit powerful domestic interest groups.” To serve these interests, there are often strings attached, such as those requiring governments to “open up to trade and foreign investors” and adhere to “enhanced patent protections” that prevent access to affordable medications. According to Nii Akuetteh, the Executive Director of Africa Action, “there are conditions that are attached where the emphasis is more on countries that open up their markets so American companies can go in and privatize things like water and electrical service or have access to certain resources.” Some of the most damaging restrictions, though, are the ones reflecting moral dogma, like the sex worker clause in the AIDS Leadership Act. This clause, however, is not without precedent. Often, a designated percentage of U.S. foreign aid for HIV/AIDS prevention must be dedicated to abstinence programs, even though many experts assert that there are more effective methods. The politicizing of foreign aid in areas of health has its roots in the Mexico City Policy initiated by Ronald Reagan in 1984; the policy prohibited recipients of U.S. international family planning funds from having anything to do with abortion, including mentioning the procedure in counseling. This “global gag rule,” retracted by Clinton but resurrected by Bush, is responsible for the closing of essential health clinics, including five in Kenya, some of which “were the only affordable reproductive health services in the area.” The AIDS Leadership Act follows this example, with devastating effects and questionable legality.
Many organizations have condemned the Act, resulting in two ongoing lawsuits brought by the Alliance for Open Society International, Inc., and DKT International, both of which have been heavily involved in preventing the spread of HIV/AIDS in Africa. Last year, over 200 charities and organizations signed a letter to Bush protesting the sex worker rule. Many of these organizations, with support from the American Civil Liberties Union (ACLU), have attacked the Act for violating the First Amendment rights of U.S. organizations. According to DKT International, the Act constrains the organization’s “speech in other programs for which it does not receive federal funds and…forces [it] to convey a message with which it does not necessarily agree” (DKT International, Inc v. USAID  at 5). Though two federal courts ruled that the Act’s policy was in violation of the First Amendment, the Court of Appeals of the District of Columbia Circuit reversed the decision in the DKT International case on February 27, 2007.
DKT International, which receives roughly 16 percent of its budget from the United States Agency for International Development (USAID), refused to sign the pledge because it would result in “stigmatizing and alienating many of the people most vulnerable to HIV/AIDS -- the sex workers” (DKT International at 4). This concern was echoed by the 25 organizations that signed the ACLU’s friend-of-the-court brief, including such varied voices as the American Foundation for AIDS Research, American Jewish World Service, Physicians for Human Rights, and Dr. Jim Young Kim, Chair of the Harvard Medical School Department of Social Medicine. According to the ACLU, “Many organizations that work to prevent the spread of HIV/AIDS often reach out to commercial sex workers to distribute condoms and offer education on safer-sex measures.” This point was emphasized by Chris Beyrer, the director and founder of the Center for Public Health and Human Rights at the Johns Hopkins Bloomberg School of Hygiene and Public Health, in a Declaration to the court in Alliance for Open Society International, Inc. v. USAID (Judge’s decision ruling against USAID). Beyrer cites USAID’s own research to support his claims: “Providing sex workers with access to education, condoms, and other prevention tools is very effective in curbing the spread of the disease within this community and the general population (UNAIDS, 2001, 2004). It is essential to involve members of the target high-risk community, such as sex workers, in delivering the message of HIV/AIDS prevention (USAID, 2001).” It was USAID, in fact, that released valuable information on the ways in which stigma and discrimination “push people in high-risk groups (e.g. sex workers, injecting drug users) underground, making them difficult to reach through prevention programs and thus creating more opportunities for HIV/AIDS to spread to the general population.” Though the political aspects of this debate are highly controversial, there is a near consensus among health experts that the pledge in the AIDS Leadership Act is misguided and harmful.
Most experts agree with Paul Zeitz of the Global AIDS Alliance, who says that the most rapidly growing HIV/AIDS epidemics “are happening among sex workers in developing countries, yet the Bush administration policy would create an even bigger crisis.” Organizations like DKT International do most of their work in these vulnerable nations, such as Sudan and Ethiopia, which have some of the highest rates of infection. According to Beyrer, groups including the World Health Organization, UNAIDS, and the World Bank have promoted working with commercial sex workers as an effective strategy to fight the epidemic. Evidence of this effectiveness is clear in nations like Brazil (which has refused to accept $40 million in American aid because of the restrictions) and Thailand; the latter having seen rates of infection in soldiers peak at over 12 percent in 1991, and then fall to under one percent ten years later, due to programs involving outreach to sex workers. Not only have organizations seen success with these tactics, but sex workers have formed their own coalitions to battle the virus. Women in the Indian state of Maharashtra created the organization SANGRAM, “a collective of female sex workers that grew to include thousands of members.” SANGRAM has worked extensively against the spread of HIV, leading to a number of international awards for their positive results. Despite these proven strategies, no organization receiving funding from the AIDS Leadership Act could effectively work with a group like SANGRAM.
The deleterious effects of attaching politically motivated strings to foreign aid are evident. The sex worker pledge in the AIDS Leadership Act could hurt states that were previously on upwards paths, such as Uganda, one of the few African countries that was reducing infection rates, but that has recently deteriorated, partly as a result of U.S. policy. Stephen Lewis, the UN Secretary General’s Special Envoy for HIV/AIDS in Africa, says that American cuts in funding for condoms and a focus on abstinence has contributed to a critical shortage of condoms. According to Lewis, “There is no doubt in my mind that the condom crisis in Uganda is being driven by [US policies]. To impose a dogma-driven policy that is fundamentally flawed is doing damage to Africa."
The fact that this administration, despite these harmful restrictions and the opting for political moralizing over saving lives, has done more for victims of HIV/AIDS in Africa than any previous administration is a testament to how poorly the United States, and other wealthy nations, have done in addressing the problem. That the AIDS Leadership Act rejects the advice of health experts in order to appease those who morally object to prostitution, though, is unconscionable, if not unconstitutional. For true progress to be made against HIV/AIDS and other diseases that plague impoverished populations in Africa and elsewhere, the United States and other nations must cooperate with local coalitions and health experts, even if it is at the expense of economic and political gain.
Aaron Sussman is a freelance journalist, activist, and co-founder/Executive Editor of InciteMagazine.org. Sussman is also a radio show host, stand-up comedian, and will soon begin working for a legal advocacy and civil liberties organization in New York City. For more of Sussman’s work, visit ACrowdedFire.com. He can be contacted at: Aaron@InciteMagazine.org.
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