Lydia Boyd provides a detailed account of how the changes in United States policy-making on HIV prevention over the past decade, from George W. Bush through to Barack Obama, have been received and understood by a group of Ugandan born-again Christian HIV activists at a church in Kampala. But, this book is much more than an account of the implementation of a policy ‘on the ground’; it provides carefully argued insights into understandings of self, the management of social change and the interface between different cultural and moral constructs. She describes how a central message of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) approach to prevention, the message ‘to be faithful’ and to ‘abstain’ from sex before marriage, took on meaning within the lives of young Christians at one church in Kampala; how the local interpretation of this message provided a way for young Christians in the church to think of themselves as accountable, self-controlled individuals, setting themselves apart. This interpretation of this moral message ran counter to the social structures in which these same young people remained embedded, the kin groups and communities where parents and elders expected respect for ‘tradition’. These were traditional codes of conduct that provided an alternative moral compass. This resulted in what Boyd describes in her epilogue as ‘conflicts about how people imagined health, proper behaviour, and moral obligation’ (p. 181). Boyd demonstrates a remarkable ability to bring together a detailed understanding of changes in HIV prevention policy, and an ethnographically informed understanding of Christian-activism in one particular setting while demonstrating a sensitivity to local understandings of ‘traditional’ concepts of behaviour and obligation.
The resulting book is a nuanced and thoughtful ethnographic account which provides detailed insights into the effects of HIV-prevention funding on people's lives and actions across 10 years in Uganda, as she came and went for prolonged periods of fieldwork. The various aspects of PEPFAR, introduced in 2003 under President Bush, have been discussed and critiqued in numerous articles, often looking at the impact such a large amount of money (and associated accountability structures) have had on receiving countries and organisations. However, to date to my knowledge, no one else has provided such a rich and detailed account not only of how certain organisations used the funding to benefit their own moral approach to sexual behaviour, but also to provide detailed ethnographic insights into the ways in which messages, such as ‘abstain and be faithful’ were recrafted to draw upon local understandings of accountability, self-control and moral behaviour.
This book deserves to be widely read, not least by those engaged in public health policy-making, in order to gain an understanding of how an external intervention is both received, shaped and used, taking on a life very different from the understanding of what it means, held by those who designed it. In this particular case, that policy is one with a very strong moral message about individual accountability and ‘proper’ behaviour. Boyd shows how Ugandan Christian groups eligible for PEPFAR funding to support programmes to roll out the messages and approaches to prevention, including ‘abstain and be faithful’, were not mere recipients of a foreign moral agenda; they used this funding and messaging to support a focus on personal success and moral uprightness in a rapidly changing urban environment. PEPFAR served such groups well, for some time. It is not surprising that the changes that PEPFAR underwent when Obama took over as President, which saw dedicated funding for abstinence programmes disappear, were seen as a betrayal by such groups. Indeed, according to Boyd, it suggested to some that the American funders (and Ugandan politicians who had been supporting the funders' messages) were now disinterested in a moral agenda which preached abstinence and faithfulness and were more interested in ‘freedom’, which some in the church interpreted to be an encouragement of immoral behaviour. They had, in the words of the Pastor who led the church that Boyd attended and studies, lost their way.
An additional strength of this book is the way in which Boyd makes use of the timing of this shift in policy to reflect on the passage of anti-homosexuality legislation in Uganda, and the way in which the Christian activists embraced this new cause as they remained ‘active proponents for “sexual morality”’. Much has been written in the popular press and elsewhere about the support of the American Christian right-wing groups for this bill, but Boyd describes how Ugandan Christians in Kampala saw their own rejection of ‘gay rights’ as being at the heart of their upholding local understandings of personhood, justice and inequality. To support such sexual rights would be to undermine the family and social structure which provides structure and support for individuals' sense of self and their place in the world. These Ugandan Christians did not see themselves as passive recipients of foreign agendas, be they shaped around abstinence or anti-homosexuality, but as people taking opportunities to demonstrate ‘self-control’ shaped by a particular cultural understanding of the self, albeit an understanding played out within a setting shaped by deeply embedded structural inequalities.
This very readable and accessible book is an excellent addition to the literature on HIV, contemporary religion and global health. It is more than an addition; Boyd provides an excellent example of insightful ethnographic research at its best.
