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Aids: when ABC is wrong

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George Bush’s emergency programme to tackle the Aids epidemic, is seriously undermined by his ‘morality doctrine’ , argues Peter Gill
Issue 2003
illustration by Tim Sanders
illustration by Tim Sanders

My new book, Body Count: How they Turned Aids into a Catastrophe, marks the 25th anniversary of the Aids epidemic, dated from 5 June 1981. That was the first medical report in the US of mysterious clusters of rare pneumonias among gay men.

The book is about the politics of Aids. Famously former US president Ronald Reagan never mentioned the word in public for five years. The Brits, under Margaret Thatcher, paradoxically had quite a good record.

I think the key contemporary issue is the George Bush programme. The President’s Emergency Plan for Aids Relief (PEPFAR) is a $15 billion commitment over five years. This dwarfs president Clinton’s expenditure in his eight years in office.

You can think of many motivations for this other than the humanitarian one, including the opportunities it represents for the evangelical movement and the pharmaceutical companies.

But it also represents lots of money for treatment. I reckon 500,000 people are alive now because of Bush-funded treatment. They would otherwise be dead or dying. They’re able to live productive lives. That’s impressive.

The problem is prevention, as this is an epidemic that is still neither curable nor properly under control.

However much of a human right it is for people, whether they are poor or not, to have the medical treatment they need, the world will not realistically be able to afford treatment for a steadily expanding epidemic.

Prevention is the only cure. My criticism is of Bush’s “morality doctrine” in his approach to Aids, which has three components. One is the so-called ABC. This has been formally adopted as the Bush prevention strategy for Africa and the countries his programme is concentrating on.

ABC stands for Abstinence, Be faithful and Condoms. The problem is that the US legislation says that ABC is the order of priority. The truth is that abstinence and fidelity campaigning are being significantly favoured over any appreciable expansion in condom services.

This overthrows a public health consensus, which, for a generation, has held that although abstinence and fidelity have a part to play, humanity is not going to abstain from sex. In epidemic situations you have to protect yourself and condoms have to be available.

There is no doubt they are downplaying condoms. There is little impressive evidence that concentrating on abstinence campaigning actually works.

There is all sorts of evidence that condom promotion works. Uganda contained Aids by promoting abstinence but also relying extensively on condoms. It became a much more balanced programme than the US gives it credit for.

According to the US government’s own reports, Bush’s people are spending $2 on A and B campaigning for every $1 on condoms.

That is regarded by most public health experts as the wrong way round.

The second component of the Bush morality doctrine is termed the anti-prostitution pledge.

Moralisers in the US Congress insist that agencies, excluding the United Nations, sign a pledge saying they are opposed to the promotion and practice of prostitution and sex trafficking.

Who is going to approve of sex-trafficking, which is an evil crime of globalisation? But there is a significant problem with the dismaying matter of prostitution, which people are driven to across the developing world as a matter of economic survival.

Prostitutes are both a key source of the epidemic and at grave risk of being infected. Is it reasonable for the US government to insist that organisations working with prostitutes condemn the practice to which their clients are driven?

Two organisations took the US government to district court under the first amendment which guarantees freedom of speech and religion. They asked, how dare the government insist that US citizens running aid agencies and in need of government funding have to subscribe to the government’s own view of things?

They both recently won their cases.

The third component, fundamental to the Aids epidemic, although not originating with the Bush programme, is the continuing ban on any federal money being spent on needle exchange programmes. This has been US policy for 20 years.

This is critical at the moment as you have got various epidemics around the world – in South East Asia, the former Soviet Union, Central Asia and eastern Europe – which are significantly driven by intravenous drug use.

Yet there is a complete federal ban on aid money to these. They get round it at home in the US because it doesn’t apply to state or city governments. But it has a significant effect given US influence and largesse abroad.

It is these three components which potentially undermine a great deal that is good about the scaling up of US commitment on Aids.

Body Count: How they Turned Aids into a Catastrophe by Peter Gill (£7.99) is available from Bookmarks. Phone 020 7637 1848 or go to Peter Gill is to speak about the book at Bookmarks, 1 Bloomsbury Street, London WC1 at 6.30pm, Thursday 1 June.

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