Democracy Dies in Darkness

Monkey Cage

What do Africans actually think about public health interventions from afar?

By Kim Yi Dionne

July 22, 2016 at 1:00 PM

British pop star Elton John signs the “Pro Test” wall to encourage people to get HIV tested at the International AIDS Conference in Durban, South Africa, on July 21. (Associated Press)

Today marks the end of the 21st International AIDS Conference, being held in Durban, South Africa. The conference is the largest conference on any global health or development issue. It features everything from presidents and pop stars to people living with HIV and the researchers studying the AIDS epidemic and its consequences.

Earlier this week at the conference, pop star Elton John committed funds from his foundation to a partnership with PEPFAR, the U.S. President's Emergency Plan for AIDS Relief. Together, they are launching the LGBT Rapid Response Fund "to expand existing initiatives to tackle HIV among LGBT people."

Related: [Elton John: LGBT people must be part of AIDS fight]

The fund will make small grants (between $5,000 and $20,000) to organizations in PEPFAR-funded countries in Africa, Latin America and the Caribbean. Many of the target countries criminalize same-sex acts, which poses challenges for anti-AIDS initiatives such as HIV testing and AIDS treatment that target, for example, men who have sex with men.

The LGBT Rapid Response Fund fills an important gap in the global response to AIDS, but given what I've learned in my research on AIDS interventions in Africa, I wonder how this intervention from afar would be received by ordinary Africans.

Related: [Anti-homosexuality bill: U.S. foreign policy and Ugandan domestic politics collide]

Two new books make a strong case for why we should wonder how international interventions are received locally. In this week's edition of the African Politics Summer Reading Spectacular, I draw from both.

In "The Experiment Must Continue: Medical Research and Ethics in East Africa, 1940-2014," Melissa Graboyes writes a beautiful ethnographic history of medical experiments in East Africa from the colonial period to the present. (A free excerpt of the book is here.)

Graboyes shows that East Africans perceived medical research very differently than researchers did. While researchers saw the goal of their projects as expanding knowledge, they sometimes promoted the programs as "therapeutic." The communities in which these research projects were implemented viewed them as "being done to benefit the individual" — the research participant. As Graboyes points out, this misconception raises questions about whether people knew they were participating in research.

An important takeaway from her book is the importance of studying past medical encounters and local understandings and priorities. Studying two filariasis programs — one in colonial Kenya and one from modern-day Zanzibar — Graboyes demonstrates the importance of local support for disease-elimination campaigns. Local support depended on previous encounters with health officials. It also depended on what people felt was important and relevant:

"Filariasis was neither a deadly disease nor extremely debilitating or stigmatized; it was unlikely to be identified as a first choice for elimination by residents. Instead, people likely would have preferred researchers to focus on other — deadly — diseases such as smallpox or malaria, or provide a true public health service like reliable access to clean water." (p. 65)

But Graboyes doesn't just caution us to look to the past; she also persuades us to think about the future. Her study of two malaria-eradication programs shows how important it is to think about the longer term consequences of interventions. While a colonial anti-mosquito experiment "almost completely eradicated" malaria, it stopped short, which actually led to a dangerous change in the local disease ecology and a significant rebound of resistant forms of malaria.

Because "The Experiment Must Continue" shows that East Africans were not just passive recipients of medical interventions but active contributors, researchers must consider the risk and potential harm their projects could have — even if only to serve their own interests in completing their research.

Like Graboyes's book, Lydia Boyd's book, "Preaching Prevention: Born-Again Christianity and the Moral Politics of AIDS in Uganda," shows the importance of understanding local reception of an international intervention. (A free excerpt of the book is here.)

"Preaching Prevention" examines how PEPFAR was received in Uganda. In her words, Boyd studies "how African recipients of a public health program took up and transformed a lesson about accountability, emphasizing both the appeal and the limitations of a global approach to AIDS prevention" (p. 4). Boyd examines in particular the experiences of Ugandan born-again Christians promoting abstinence and faithfulness programs in Kampala, the capital city.

PEPFAR is the largest funded effort against HIV/AIDS in the world and was a commitment originally made by President George W. Bush during his 2003 State of the Union address. Between 2004 and 2015, PEPFAR spent (or committed to spend) almost $73 billion on HIV/AIDS, tuberculosis and malaria programs around the world, but primarily in Africa.

In the country in which Boyd's study is situated, Uganda, PEPFAR spent $278 million in 2014, which was equal to about three-fourths of what the Ugandan government spent on health overall that same year. In other words, Boyd is studying the critical player in public health provision in Uganda.

Boyd's book seems particularly relevant for the newly created LGBT Rapid Response Fund, as it includes a chapter about Uganda's Anti-Homosexuality Bill. In it, she shares one church member's criticism of Western priorities: "When you come and talk about homosexuality, when there is a mother who can't feed her children, how does this make sense? Why does the West care more about homosexuals than those who suffered under the LRA [Lord's Resistance Army]?" (p. 163)

Even as the LGBT Rapid Response Fund fills an important gap, these ethnographic histories of medical interventions in Africa remind us about the importance of local priorities and the potential for backlash.

READ MORE in this year's African Politics Summer Reading Spectacular: 


Kim Yi Dionne is Five College Assistant Professor of Government at Smith College. She studies identity, public opinion, political behavior, and policy aimed at improving the human condition, with a focus on African countries.

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