Foreign AIDS

America's overseas social engineering


A Republican effort to stamp out needle-exchange programs abroad incensed editorial boards at the Washington Post and New York Times last weekend, and both pages slammed the latest Congressionally-mandated gag rule to hit the United Nations. That conservatives are trying to stamp out harm reduction abroad is no small story, but both pages missed the fact that this is only the latest installment in a long story of strings-attached giving that has been changing U.S. foreign aid policy for years. From AIDS prevention measures stigmatizing sex, to anti-human trafficking targeting prostitution, to drug policies purged of pragmatism, foreign aid has become an American adventure in social engineering.

Global AIDS conferences have become as much a matter of America-bashing as AIDS-fighting. Last July, U.S. AIDS coordinator Randall Tobias was heckled mercilessly at the International AIDS conference in Bangkok. The discord stems from U.S. gestures toward a comprehensive approach on AIDS that never quite panned out. The Global Fund to fight AIDS, Tuberculosis and Malaria was founded three years ago as a multilateral effort to help funnel vast sums of money to developing countries in need of public health funding. It took a localized, hands-off approach, scrutinizing applications but generally leaving questions of implementation and disbursement to local agencies and governments. The U.S. offered the first grant of $200 million and was expected to be a major supporter.

But during the president's State of the Union Address in 2003, he busted out with something called the "President's Emergency Plan for AIDS Relief," or PEPFAR, and a competing bureaucracy was born.

PEPFAR was smaller in its ambitions—only 15 countries were targeted—but much better funded, with $15 billion promised over five years. The Global Fund's biggest donor had proven itself capable of promising huge sums of money, but they would not be going into the Global Fund. Tobias tried to stem the ensuing wave of criticism by claiming that the organizations could work together. But it soon became clear that they had fundamentally different missions. PEPFAR enthusiastically endorses the so-called "ABC" approach—Abstinence, Be Faithful, and Condoms. The program gave President Bush an opportunity to scale up from his $10 million abstinence crusade in Texas (where there is no evidence it worked) to a billion dollar version in Africa (where there is new evidence it's not helping.)

PEPFAR promises that 33 percent of all funds are spent on abstinence-promotion and that faith-based organizations can receive funding even if they refused to talk about or provide contraception. Condoms, the most statistically proven and economically sound method of prevention, are a last resort to be distributed to "high-risk" groups. The program also forces any organization receiving funds to explicitly oppose the legalization of prostitution.

The anti-prostitution demand is major, and it affects anti-human trafficking funds as well as AIDS funding. NGOs and organizations fighting trafficking are likely to be working against the stigmatized, underground nature of illicit prostitution, but they can't accept U.S. funds unless they condemn the practice. In the U.S., the push for action on human trafficking has come from the Christian right, and the lines between victim and sex worker have all but disappeared. U.S. funds go to outfits like the International Justice Mission, which has been accused of "brothel raids" in which its representatives "rescue" Asian sex workers against their will. Human trafficking is a much bigger issue than sexual slavery, but U.S. efforts thus far have focused almost exclusively on women, children, and sex work.

With sexually active Africans and Southeast Asian prostitutes on the hit list, intravenous drug users couldn't be far behind. Representatives Mark Souder (R-Ind.) and Tom Davis (R-Va.) are now trying to keep American aid money out of the hands of any organization that promotes clean needle exchanges. Assistant secretary of state Robert Charles has already succeeded in scaring the United Nations Office of Drugs and Crime (UNODC) out of mentioning harm reduction in its literature, and UNODC projects are being threatened. Their actions have sent a ripple of terror through the network of international organizations. Martin Jelsma, a program coordinator at the Transnational Institute, has been following the tension between the U.S. and UNODC for years. He worries that the current pressure "threatens the very heart of the few proven methods that are effective to stem the spread of HIV/AIDS."

As with condom distribution programs, there is no real question that needle exchange programs are effective in reducing AIDS transmission. In a hearing he held last month (tellingly titled "Is there such a thing as safe drug abuse?"), Souder didn't take long to reveal the root of his antipathy to harm reduction, and it had nothing to do with his alleged doubts about efficacy. "These lifestyles," he said, "are the result of addiction, mental illness, or other conditions that should and can be treated rather than accepted as normal, healthy behaviors."

Souder's objections have to do with determining what is "normal" and "healthy" for other people; preventing AIDS transmission isn't on his agenda. As with the rest of U.S. AIDS assistance, his policies are more concerned with shaping a certain kind of global citizenry than stopping a virus. The New York Times editorial calls this a "triumph of ideology over science," but Souder and his coterie simply have different goals in mind. If keeping condoms and clean needles out of foreign hands are worthwhile goals in themselves, the science doesn't matter. Stopping the spread of AIDS would be a bonus, but it's not the priority, and it hasn't been for a long time.

Souder and others will talk of halting funding, but funding will only be redirected elsewhere. The UNODC has already buckled. The U.S. contributes far more than any other government to the fight against AIDS, and NGOs that depend on USAID will change their policies to survive.

"Compassionate conservatism" used to be a punch line, but it's in full swing these days, and it appears to involve throwing huge sums of our money into programs that don't work. If compassionate conservatism turns out to be neither, it will indeed be U.S. policy that finally brings wealthy Americans taxpayers and impoverished AIDS victims together. Both will be paying the price.