JUNE 30, 2003
Although President Bush has pledged $15 billion to fight global AIDS over the next ten years--an impressively generous sum, assuming his tax cuts don't swallow up the money before it's spent--he clings to a very specific idea about how AIDS-prevention money should be spent: on teaching abstinence. That's why he and his supporters constantly talk up the success of Uganda. Ten years ago, 15 percent of the country's population had AIDS. Today, just 5 percent do. And a major reason for the drop is an AIDS program that conforms to White House notions of propriety. As Ari Fleischer explained recently, Uganda puts "an emphasis where emphasis belongs, which is on abstinence."
A few weeks ago, I got a glimpse of a very different AIDS success story-- Brazil's--when officials there arranged a tour for a group of journalists. The Brazilian initiative dates back to the 1980s, and it is perhaps best understood through some of the public service commercials that have aired on television since then. In one, dancers from Carnival, costumed in ancient Roman garb, remind viewers that condoms have a long, distinguished history: "In Rome and ancient Egypt, no one knew who they slept with. Marco Antonia used to wear it. . .. Cleopatra demanded and believed in it. ... Hey, put on a condom." Another spot you might describe as "Father Knows Best" meets "Queer as Folk" takes place in a suburban home and preaches the virtues of tolerance toward gays as well as safe sex. Some ads play out like soap operas, such as the one in which a man cheats on his wife, picks up the AIDS virus, then gives it to his spouse. This commercial, too, promotes condom use.
It's easy to see why Bush and his conservative supporters don't talk about Brazil. But its results have been impressive. Brazil estimates that just 600, 000 of its citizens are HIV-positive today--about half of what the World Bank had predicted. The death rate from AIDS has fallen, too--by more than 70 percent in the last decade.
Of course, there's a lot more to the story than just condoms. As in most of the developing world, few Brazilians have enough money to buy the anti- retroviral drugs that keep AIDS from becoming a death sentence. Nor could the debt-strapped government afford to finance those purchases on its own, at least as long as the drugs were available only at market prices. So, a few years ago, Brazil announced it would break existing patents and manufacture generic versions domestically if the drug-makers didn't lower their prices voluntarily. Once the Clinton administration dropped its threat of trade sanctions against Brazil--threats made at the behest of the drug industry--the pharmaceuticals gave in. The United States agreed to recognize that developing countries had a right to break drug patents in order to fight a deadly public health crisis, while the pharmaceutical companies discounted a few medications. As a result, today every Brazilian who qualifies medically for AIDS therapy can get it. (Even more impressive, a recent study in the journal AIDS suggested that the rate of HIV-positive Brazilians who have developed resistant strains of the virus compares favorably to the United States and most of Europe. That would mean Brazilians aren't just getting the drugs; it would mean they're taking them properly, too--proof that, contrary to the assertions of pharmaceutical companies, patients in less developed countries can be counted on to follow the rigid regimen the medications demand.)
Brazil's progress is particularly remarkable given its government's inability to combat both the country's vast economic inequality and its truly frightening rate of violent crime. And, given that 75 percent of the country is Catholic, it's no less amazing that the population has countenanced such frank talk about sex--and that the aggressive response dates back even to the epidemic's early days, when it primarily affected gays and prostitutes. But the Brazilians I met all found this state of affairs normal. The Brazilian wing of the Catholic Church has a long history of progressive views--in part because its lineage lies with the Portuguese Church, always more open-minded than its Spanish counterpart. More important, though, Brazilians seem unusually determined to separate church and state--or, at least, religion and public policy. Brazilians don't want public health policies that pretend people don't have sex, sometimes promiscuously, nor do they want government moralizing. So they're happy to let elected officials mandate sex education in the public schools, distribute clean needles to drug addicts, and even underwrite a condom factory in the Amazon. (Brazilian officials are particularly proud of the condom factory, which they tout as a policy trifecta: It fights AIDS; brings jobs to poor, rural communities; and saves the rainforest, since latex is harvested from live trees.) When I asked Paulo Teixeira, director of Brazil's AIDS program, about political resistance to such initiatives, he seemed positively baffled: "No federal official has ever lost a job because of offending public sensibilities on sex."
Alas, that's not the case here. Just ask former Surgeon General Jocelyn Elders, forced out in 1994 for discussing masturbation. Even today, that sensibility undermines U.S. policy on AIDS. Last week, the Centers for Disease Control and Prevention (CDC) threatened to rescind its funding of a San Francisco program called stop AIDS. In order to attract more participants, the organizers mixed in some "better sex" tips with "safe-sex" talk, prompting religious conservatives to attack it as promoting promiscuity. As an office ostensibly dedicated to science, the CDC should judge programs strictly on their results. But the stop AIDS decision is part of a wider campaign to audit all federally funded AIDS-prevention programs and steer them toward abstinence training. Never mind the studies suggesting the limits of that approach in the United States--or that, even in Uganda, it hasn't been quite the elixir conservatives would have us believe. The White House has its own story about AIDS. And it's sticking to it.