Us foreign policy regarding the spread of disease in nigeria

The convergence of American and Nigerian religious conservatism in a biopolitical shaping of Nigeria’s HIV/AIDS prevention programmes

Jlateh V. Jappah*

Institute for Global Health, University College London, London, UK

(Received 5 March 2012; final version received 27 November 2012)

Nigeria has the largest number of HIV/AIDS cases inWest Africa, with 3.3 million people estimated to be living with the disease. The country remains a fragile democratic state and has allocated insufficient resources to combat the spread of HIV/AIDS among its citizens. The preponderance of President’s Emergency Plan for AIDS Relief (PEPFAR) dollars, expert knowledge, conservative ideology and activities has shaped the direction of HIV/AIDS sexual-transmission prevention programmes in Nigeria. PEPFAR channels significant resources through Nigerian faith-based organisations (FBOs), and considers these organisations integral for HIV prevention strategies. In many instances, HIV/AIDS prevention programmes managed by FBOs reflect their ideologies of morality and sexuality. There is a convergence of religious ideology concerning morality and HIV infectivity between American and Nigerian conservatives; this produces a fertile ground for the influence and expansion of the conservative activities of PEPFAR in Nigeria. The paper highlights this nexus and draws attention to the biopolitical underpinning of PEPFAR in shaping Nigeria’s HIV prevention programmes. The paper further notes both positive and negative effects of PEPFAR activities and attempts by the Obama administration to redirect PEPFAR to a more holistic approach in order to optimise outcomes.

Keywords: Nigeria; religious conservatism; PEPFAR; HIV/AIDS; biopolitics

Introduction

Within the past two decades, African states have been transitioning from autocratic

rule to more representative forms of governance. Bassett and Straus (2011) note that

in 1989, only five states in sub-Saharan Africa had democratic multiparty political

systems. Conversely, they note that by the late 1990s, the trend had changed with

only four countries in the region that had not transitioned to holding multiparty

presidential or parliamentary elections. However, Bassett and Straus attest that the

rise of democratic governance in sub-Saharan Africa has not been flawless, and cite

instances of fraudulent elections and coup d’états. Yet this new trend of representa-

tion has been spreading and has spurred a new wave of civil societies and grassroots

organisations demanding rights and entitlement programmes from their governments

and the international community at large. Further, De Waal (2006) notes that

African electorates have not made HIV/AIDS a top priority despite the havoc the

disease continues to wreak. He argues that despite the conspicuous inaction or

denialism exhibited by many African leaders regarding HIV/AIDS, the disease does

*Email: jlateh.jappah.10@ucl.ac.uk

Global Public Health, 2013

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# 2013 Taylor & Francis

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not threaten the political power of the continent’s leaders. Against this background,

De Waal argues that African leaders’ responses to HIV/AIDS lack the urgency and

scale commensurate with its devastation. Nigeria is no exception in following a similar trend. The country has the largest

number of HIV/AIDS cases in West Africa. The burden of HIV/AIDS has increased

significantly; 3.3 million people are estimated to be living with the disease today in

Nigeria, and it ranks third in the world in terms of absolute numbers, after South

Africa and India. Also, 220,000 deaths occur annually from AIDS in Nigeria,

ranking it second globally (UNAIDS 2010). The inadequate attention given to HIV/

AIDS health-related matters is partly caused by a lack of political stability in Nigeria

over the years. The country has endured a history of successive military regimes and

currently has a fragile democratic government and an increasing radical Islamic

militancy. Sufficient resources have not been allocated by the government to combat

the spread of HIV/AIDS. Nigeria’s HIV policies have been mainly donor driven, and

the US President’s Emergency Plan for AIDS Relief (PEPFAR) plays the lead role.

The USA recognises Nigeria as a strategic partner in the region, both for its large

Muslim population and its hydrocarbon wealth (Ingram 2007; Carson 2010). Johnnie

Carson, the US Assistant Secretary of State, provides critical insight into US policy in

Nigeria when he states that ‘Nigeria is one of the two most important countries in

sub-Saharan Africa, and what happens in Nigeria has consequences for Africa, the

United States, and the global community’ (Carson 2011, p. 4). Nigeria’s peacekeeping

efforts have been unparalleled in maintaining the security of the region, especially in

former trouble spots like Liberia, Sierra Leone and Co ˙ ˆte d’Ivoire. HIV prevalence

among Nigerian uniformed personnel has been an important policy subject. It has

been suggested that military personnel serve as vectors for HIV and have the

potential to foster the spread of HIV/AIDS in neighbouring countries. The USA

has allocated a large amount of money to Nigeria to combat the spread of the

disease.

The US government has been pivotal in formulating health policies geared toward

improving the health status of Nigerians. PEPFAR HIV/AIDS activities include

antiretroviral treatment, prevention of HIV infection from mother to child and HIV/

AIDS awareness programmes for military personnel and the general public. PEPFAR

is also involved in improving the country’s health care infrastructure and institutional

capacity. A strategic aim of PEPFAR is to change sexual practices and behaviours.

PEPFAR collaborates with Nigerian government agencies, local Nigerian and

international non-governmental and faith-based organisations (FBOs), as well as

US government agencies and universities to implement HIV/AIDS relief programmes.

FBOs are prominent PEPFAR implementation partners. Among them are Catholic

Relief Services AIDS Relief, Christian Health Association of Nigeria, Christian

Aid Community Based Care of Orphans and Vulnerable Children (OVC), Christian

AID Community Care Nigeria, Catholic Relief Services 7 Diocese, Catholic Relief

Services – Scale Up Nigeria OVC and Catholic Secretariat of Nigeria (United States

Diplomatic Mission to Nigeria 2012). As PEPFAR administrators, US bureaucrats

and technical experts have been highly influential in formulating Nigerian HIV/AIDS

prevention policies and in framing the Nigerian National Strategic Framework

(2010), the country’s HIV/AIDS policy document. In this paper, I highlight a shared

conservative ideology between Nigerian and American religious/political leaders. This

Global Public Health 313

ideology underpins the foundation of HIV/AIDS sexual-transmission prevention

programmes in Nigeria through a biopolitical production of life.

The biopolitical conceptual framework

Foucault (1998) writes that since the Classical Age,Western societies have transitioned

frommeans of deduction (taking of life) to exert a positive influence on life (production

of life). He notes that ‘… the ancient right to take life or let livewas replaced by a power

to foster life or disallow it to the point of death’ (p. 138). According to Foucault:

Power would no longer be dealing simply with legal subjects over whom the ultimate dominion was death, but with living beings, and the mastery it would be able to exercise over themwould have to be applied at the level of life itself; it was the taking charge of life, more than the threat of death, that gave power its access even to the body. (pp. 142–143)

This paradigm seeks to harness life, as the influence of power is only applied to living beings, and death represents the limits of power. Political power now predominantly

regards man through the lens of his biological characteristics, characteristics that are

intertwined with his economic potential within a collective body. Its highest function

is to invest in the production of a healthy life, which will ensure the economic

functions of the body.

Foucault notes that governmental management in the biopolitical economy of

power aims to regulate/maximise the population’s health by averting diseases and

accidents, lowering mortality rates, increasing longevity, stimulating fertility and birth rates, increasing economic productivity and so on. It involves the governing of

population health, with statistical applications categorising diseases and non-

diseases, as well as the prevalence and incidence of diseases, trends, projections

and consequences of diseases if left untreated. As such, Elbe (2005, p. 406) contends

that ‘… disease could no longer be left to the random fluctuations of nature, but

would have to be brought under continuous political and social control’.

Governments engage in shaping demographic indicators for the betterment of

populations. Foucault writes that ‘for capitalist society, it is the biopolitical which was of first importance, the biological, the somatic, the bodily. The body is above

all a biopolitical reality; medicine is a biopolitical strategy’ (quoted in Curtis 2002,

p. 512). According to Foucault, the biopolitical form of power focuses on ‘man as a

species’ and is aimed at the collective body (population). It forms the basis of the

biological process with the aim of increasing population productivity through control

and governmental intervention. Thus, biopolitics is a subsection of politics (polis)

that focuses on the biological life/human population (bio).

Foucault (1998) observes:

Power must be analyzed as something, which circulates, or rather something, which only functions in the form of a chain. It is never localised here or there, never in anybody’s hands, never appropriated as a commodity or piece [of] wealth. Power is employed and exercised through a netlike organization. (p. 98)

The confluence of power extends beyond territorial boundaries. As such, Mbembe

(2003) notes that ‘it makes little sense to insist on distinctions between “internal” and

“external” political realms, separated by clearly demarcated boundaries’ (pp. 31–32).

314 J.V. Jappah

In an attempt to protect population health, powers in the West appear to be moving

from the competitive nature of Westphalian nation-states to a model that galvanises

sovereign entities into prioritising the welfare of populations.

The biopolitics of PEPFAR: Nigeria

Nigeria plays a strategic role in the region. It is Africa’s second-largest economy and

the most populous country in Africa. In order to avert a fate similar to that of many

Southern African countries in which approximately one-third of the adult population

is HIV positive, it is imperative to address the HIV/AIDS epidemic in Nigeria. At the

crucial juncture of global HIV unease, the US government took the lead.

Addressing the USA Congress in 2003, President George W. Bush asserted that ‘… seldom has history afforded a greater opportunity to do so much for so many’

(PEPFAR 2011), when announcing the USA’s plan to respond to the global HIV/

AIDS pandemic. He emphasised the need for the USA to seize the opportunity in the

time of HIV/AIDS unease to act compassionately in combating the disease.

PEPFAR became the masterpiece of the president’s vision. PEPFAR was approved

by the USA Congress in May 2003. It allocated US$15 billion to combat the spread

of HIV/AIDS, tuberculosis and malaria globally within a five-year period beginning

in 2004 to the end of 2008. The ambitious plan aimed to provide a comprehensive strategy to prevent 7 million new HIV cases, treat at least 2 million people with life-

extending HIV/AIDS drugs and provide human care for 10 million people with the

disease, including children who became orphans due to AIDS. A Reauthorization

Act was signed into law in 2008, just before President Bush left office, allocating an

additional US$48 billion for the years 2009 through 2013 for PEPFAR activities.

PEPFAR has been cited as either the only or the most successful story of the Bush

Administration.

The politics of PEPFAR have been and continue to be highly polemical, with different interest groups contesting the direction of PEPFAR, especially prevention

programmes that address the sexual transmission of HIV. Evangelical Christians in

the USA and their counterparts in Africa, the Catholic Church and other FBOs,

gender-based advocacy groups, human rights organisations, social movements,

health experts and politicians have vied to tilt the pendulum of PEPFAR in their

direction. American national politics of social conservatism versus progressivism

over morality and sexuality have been brought to the global stage, engaging both

supporters and dissenters. Religious conservative ideology played an important role in the formulation of

PEPFAR (Ingram 2007, Leventhal 2010, Pereira 2011). Evertz (2010) traces

PEPFAR’s ideological stance from the Reagan Republican Administration through

the passage of the Adolescent Family Life Act in 1981, which aimed to prevent

premarital teen pregnancy in the USA by promoting chastity and self-discipline. He

notes that earlier government grants for the programme were given ‘exclusively to

far-right and religious groups.… developing programs that explicitly promoted

religious values’ (p. 7). In formulating PEPFAR legislation, President Bush, a born-again Christian,

responded to his religious base. Ingram (2005) argues that the implementation of

global AIDS relief by the Bush Administration was partly in response to pressure

from evangelical Christian groups in the USA. These groups shaped the legislation to

Global Public Health 315

reflect their core conservative values. Ingram (2007) highlights that ‘the moralizing

dimension of US HIV/AIDS relief carries strong echoes of colonial and missionary

projects of civilization, but encounters African societies themselves undergoing

religious revivalism’ (p. 527). Pereira (2011, p. 2) writes in a similar vein that

‘biomedicine in the world’s former colonial territories was introduced as a tool of

civilization and evangelization by Christian missions which pioneered and largely

dominated the field—as well as by philanthropic entities and states authorities’.

Senate Majority Leader Bill Frist and Senator Jesse Helms (who had earlier claimed

that HIV/AIDS mainly affected people who engaged in sodomy), played a crucial

role as conservatives in the formulation of PEPFAR (Dietrich 2007). Bush and fellow

conservatives became passionate about helping HIV victims based on their belief in their moral responsibility to assist the sick and help restore life.

Phyllis Schlafly (2003), an influential conservative activist, wrote President Bush

a month before PEPFARwas signed into law, urging the president to sign a bill only

if it contained legislative language codifying his priorities. She suggested that such

priorities include changing behaviour, abstinence, faithfulness and avoidance of

abortion. This born-again doctrine was argued to be the most effective and low-cost

way to mitigate the spread of HIV. Schlafly implored the president to make

‘A’ (abstain) and ‘B’ (be faithful) leading priorities in PEPFAR legislation. Schlafly

advocated that PEPFAR prevention funds be based on what she claimed to be

‘Uganda’s “ABC” approach’ and asserted that this ‘model prioritizes abstinence,

being faithful to a monogamous partner, and only as a last result, condoms’

(Leventhal 2010, p. 204). Schlafly noted that the Catholic Church cares for one in

four people treated for AIDS worldwide and that FBOs should play a key role in

PEPFAR HIV prevention. PEPFAR legislation reflects similar principles:

…Uganda’s successful AIDS treatment and prevention programme is referred to as the ABC model: “Abstain, Be faithful, use Condoms”, in order of priority.…Beginning in 1986, Uganda brought about a fundamental change in sexual behaviour by developing a low-cost programme with the message: “Stop having multiple partners. Be faithful. Teenagers, wait until you are married before you begin sex”. (PEPFAR I. H.R. 1298, p. 4)

Historically, Christian and Islamic proselytisers had gone to Africa earlier on and

their indelible imprint remains. As Matua (2002) points out:

…At the core of attempts to subjugate Africans to the messianic tradition is a belief not only in the superiority of the missionary and his or her messianic dogma but also in the sub-humanity of the missionary’s subjects and their cosmology. (p. 227)

Catholicism, Protestantism, Pentecostalism and Islamism have displaced many

African traditional religious rituals (Mbiti 1969, Matua 2002). Similarly, PEPFAR

and its conservative messages concerning HIV sexual-transmission prevention have

been transported to Africa, with hopes of changing deep-rooted practices.

With the USA providing such a colossal sum of money through PEPFAR, which

remains unparalleled in history, it is not surprising that US policy-makers would

attempt to direct health care policy in PEPFAR recipient countries, including

Nigeria. The PEPFAR Prevention Technical Working Group provided significant

input into the revised 2003 Nigerian National Strategic Framework (PEPFAR 2008).

The policy document employs similar strategies that are prominent features of

316 J.V. Jappah

PEPFAR legislative mandates. Some of these strategies do not necessarily reflect

evidence-based measures or general consensus among public health practitioners.

Rather, they aim to appease religious organisations and donor partners.

PEPFAR legislation charged the US Global AIDS Coordinator with establishing HIV sexual-prevention strategies governing the expenditure of PEPFAR funds in

countries with generalised epidemics. The legislation earmarked funds for disburse-

ment beginning in 2006–2008 as follows: 55% for HIV/AIDS treatment, 15% for

palliative care for HIV victims, 20% for HIV/AIDS prevention programmes with at

least 33% of this amount specifically for abstinence-before-marriage programmes

and 10% to help orphans and other vulnerable children. Ingram (2007) cites the

Center for Health and Gender Equity in stating that ‘one analysis estimates the share

of funds channeled to “abstinence-only” strategies for the prevention of sexual transmission of HIV in Nigeria at 70%, far in excess of that implied by the legislative

ceiling of 33% of prevention funds’ (p. 527). Ingram further notes PEPFAR’s direct

provision of antiretroviral drugs for Nigeria’s military forces (commonly provided by

the sovereign state) as a novel biopolitical commitment to protecting and

maintaining a foreign military.

Generally, there is a marginal difference between PEPFAR practices in different

countries in the region. The conservative religious undertone of PEPFAR is also

apparent in other PEPFAR partner countries. The ABC model originated in Africa, and was borrowed and reshaped by the Bush Administration. The United States

Government Accounting Office-06-395 (2006) notes that half of the country teams

stated that ‘the spending requirement can undermine the integration of prevention

programmes by forcing them to isolate funding for AB activities’ (p. 6). In 2007,

prior to PEPFAR II (the Reauthorization Act), the US Institute of Medicine of the

National Academies found that PEPFAR I budget allocations that set percentage

levels on prevention, care, treatment and activities within prevention programmes (1)

have adversely affected implementation programmes; (2) inhibited comprehensive, integrated and evidence-based approaches; (3) have been counterproductive; and (4)

have limited the ability of PEPFAR programmes to tailor activities to meet country-

specific epidemics and coordinated activities in countries’ national programmes. The

US Senate had hearings on the lack of evidence-based approaches within PEPFAR

(H.R. 5501, 2008). As Leventhal (2010) explains, senators promised to amend the

legislation to better reflect local epidemiological needs. Thus, the Reauthorization

Act calls for a balanced approach in prevention activities for sexual transmission,

‘… ensuring that activities promoting abstinence, delayed sexual debut, monogamy, fidelity, and partner reduction are implemented and funded in a meaningful and

equitable way in the strategy for each host country based on objective epidemio-

logical evidence’ (pp. 49–50). However, PEPFAR II specifies that the US Global

AIDS Coordinator must report to the US Congress within 30 days if less than 50%

of prevention funding is not spent on AB activities, a reiteration that PEPFARwould

not radically deviate from its founding principles.

Religion, morality and sexuality in HIV prevention programmes in Nigeria

In Nigeria, religious conservatives in many ways align with PEPFAR creators. There

have also been concerted efforts between Nigerian and American conservatives to

influence policies affecting people living with HIV/AIDS (PLWHA) in Nigeria.

Global Public Health 317

Hybrid alliances have been forged between these groups and their shared beliefs have

led them to gravitate toward a common pole. In 2004, more than 30 FBOs

and NGOs in Nigeria collaborated to create the Nigeria Abstinence Coalition.

The organisation, an affiliate of the US-based Abstinence Clearinghouse, purport-

edly aims to advance abstinence and fidelity messages and practices (Abstinence

Africa 2004, Human Rights Watch 2004). Mafeni and Fajemisin (2003) note that during the early stages of the HIV

epidemic, many churches in Nigeria adopted compulsory HIV testing before

marriage, and refused to allow those found positive to get married in churches.

Although this decision was later recanted by the highest levels of church leadership,

the practice remained prevalent in local parishes. Local religious leaders may not

fully comply with official positions of higher levels of leadership. Further, many

evangelical churches are non-denominational and do not conform to a hierarchical

structure. A majority of religious leaders in Nigeria share similar positions on

premarital sex. Core religious messages, as suggested by Ucheaga and Hartwig

(2010), emphasise abstinence outside of marriage and faithfulness within marriage.

They note that fear messages are promoted among Christians and Muslims, and

both groups threaten damnation and a life in hell for those who do not conform.

Further, the Catholic Church vehemently opposes the use of condoms, asserting that

it counters God’s plans regarding procreation. Evertz (2010) notes that conservatives

in the USA were less motivated to provide condoms to the world’s population

because it would appear to be an implicit endorsement of premarital sex. Ucheaga and Hartwig (2010) note that the majority of religious leaders in Nigeria

do not promote condom use for HIV prevention, and these leaders believe that

collaboration with the Nigerian government is worthwhile as long as the government

does not attempt to force religious organisations to support condom use. The general

view is that condom use promotes promiscuity and is not a reliable means of HIV

prevention. Notable exceptions to this view are the Anglican Church in Nigeria,

some branches of the Lutheran Church and the All African Conference of Churches,

which support the use of condoms (Iliffe 2006).

The conservative message regarding condom usage resonates not only with

religious leaders, but also with some governmental and regulatory authorities in

Nigeria. In 2001, a radio advertisement was suspended by the Advertising

Practitioners Council of Nigeria because it was deemed to convey the message

that premarital sex is acceptable as long as a condom is used (AVERT 2011). In 2006,

stricter regulations on condom advertising were enforced so as to discourage

presumed indecency. Aversions to condom use, although mainly framed in religious terms, have diverse antecedents. Iliffe (2006) attributes low condom use at the

beginning of the HIV/AIDS epidemic in Africa to a widespread distaste among both

men and women. Condoms were at first almost exclusively used among sex workers,

such that women who insisted on condoms were viewed as prostitutes. Iliffe cites

Mwangi’s analysis that ‘the men were too manly to use them and the women were too

womanly to insist’ (p. 134). Engel (2006) notes that many Africans associated

condom use with efforts at genocide, homosexuality and emasculation. Some men

rejected condom use because of the financial cost and others because they preferred

sexual contact with flesh. Despite social aversions, the scientific community clearly

views condom use as imperative in curbing the spread of the virus, while

conservatives in the USA and Nigeria stubbornly propagate the contrary.

318 J.V. Jappah

In 2004, the Nigerian president asserted that ‘homosexuality is clearly un-Biblical,

un-natural, and definitely un-African’ (AVERT 2011). Homosexual practices are

illegal and highly stigmatised in Nigeria. American conservative Christians have

actively advocated for legislation criminalising homosexuality in some African

countries. As an example, Uganda’s Anti-Homosexuality Bill, supported by evan-

gelical pastor Rick Warren, has been used as a model for the proposition of similar

legislation in Nigeria.

In West Africa, according to Ucheaga and Hartwig (2010), people in organised

religion primarily receive information on health-related behaviour, sexuality and

morality from religious leaders. These leaders and their core messages are highly

relevant in regard to how people perceive of themselves and HIV since the virus has

been framed in terms of health, sexuality andmorality.Dilger et al. (2011) observe that:

religious traditions are manifested in sexuality and reproduction; the emergence of HIV has been co-productive in the emergence of new religiosities that inform individual and social identities, and which consequently have a bearing on policies and political and economic realities. (p. 373)

PEPFAR legislation asserts that since many Africans are affiliated with a religious

institution, FBOs possess important experience that is needed to carry out prevention

programmes. PEPFAR Nigeria particularly encourages local FBOs to apply for

PEPFAR funding. PEPFAR mobilises religious leaders to include HIV prevention

messages in their weekly sermons in churches and mosques (PEPFAR 2008). These

sermons reinforce messages of moral-sexual chastity in HIV/AIDS prevention. Moral judgments are proselytised through religious beliefs, which in turn impact

sexual practices promoted by AIDS prevention programmes. Dilger et al. (2011)

further observe that in sub-Saharan Africa, certain Christian organisations have

constructed HIV infection as a punishment from God, a belief that has resulted in

the dichotomy between ‘good/pure’ and ‘bad/impure’ Christians. HIV/AIDS has

been presented in the public discourse as divine retribution for individual or societal

failure to adhere to sanctioned modes of conduct. Similarly, Smith (2004) notes that

in Nigeria, the framing of HIV/AIDS as a social problem resulting from immorality

reflects a common perception that the nation’s most entrenched social problems also

result from moral decadence. The framing of HIV/AIDS as divine retribution has

been criticised by researchers and activists as contributing to the stigmatisation of

PLWHA, which impedes efforts to reach those most at risk. Smith (2003) writes that

‘one prevailing discourse is that AIDS is a scourge visited by God on a society that

has turned its back on religion and morality’ (p. 364), a belief that resonated with US

conservatives at the onset of the HIV epidemic. Smith further suggests that Nigerian

youth have a deterministic view regarding HIV infection. He notes that ‘strong

religious ideas about the role of God in determining fate combined with a belief that

God protects those who behave morally exacerbate a cycle of stigma and denial that

very much characterises popular responses to AIDS in the communities’ (p. 346).

People believe that God causes AIDS, and whether or not they become infected is

determined by God (Smith).