She's Married, She's Faithful, She's Dying: Politicizing the President's Emergency Plan for AIDS Relief

Abstract

Conservative Christians played a significant role in pioneering the United States’ groundbreaking anti-HIV funding initiative, the President's Emergency Plan for AIDS Relief (PEPFAR). Consequently, PEPFAR is widely regarded as George W. Bush's crowning achievement. The same political forces that ushered in PEPFAR under President Bush were also the architects of strict ideological restraints around the otherwise straightforward public health goal of curbing the spread of HIV/AIDS. In recent years, some of these restrictions have been rolled back or struck down by the U.S. Supreme Court, and PEPFAR has continued to serve a crucial role in global health and security. PEPFAR's future success in achieving its health mandate (to create an AIDS-free generation) will be influenced by lessons from its past. This article illuminates how, in its first decade, PEPFAR was directed toward the fulfillment of socially conservative goals that ran counter to its official agenda. This was accomplished in large part through two controversial provisions: the “anti-prostitution pledge” (2003–2013) and the “conscience clause” (2003–present). Working in tandem, these policies sought to secure funding for organizations that favored abstinence and fidelity rather than a multisectoral approach to AIDS prevention.

In the late 1990s, conservative Christian political interests in the United States shifted from a relative lack of concern with the devastation wreaked by HIV/AIDS in sub-Saharan Africa to a position of “compassionate conservatism” (Donnelly 2012, 1389).¹ Through this effort, which culminated in the 2003 President's Emergency Plan for AIDS Relief (PEPFAR), conservative Christians played a significant role in pioneering the United States’ groundbreaking anti-HIV funding initiative. Consequently, PEPFAR is widely regarded as George W. Bush's crowning achievement (Emanuel 2012, 2097). The same political forces that ushered in PEPFAR under President Bush were also the architects of strict ideological restraints around the otherwise straightforward public health goal of curbing the spread of HIV/AIDS. In recent years, some of these restrictions have been either rolled back or struck down by the U.S. Supreme Court, and PEPFAR has continued to serve a crucial role in global health and security.

This article forwards knowledge of PEPFAR by illuminating the architecture of PEPFAR's controversial early provisions, which shaped it as a socially conservative policy. It does so by shedding light on how two policies—the “anti-prostitution pledge” (2003–2013) and the “conscience clause” (2003–present)—worked in tandem as elements of the PEPFAR legislation to secure funding for organizations that focused on abstinence and fidelity rather than a multisectoral approach to AIDS prevention. The significance of how these two policies worked together to shape the framework of PEPFAR has not been considered to date, but it was their mutual reinforcement that initially gave the legislation such strict ideological direction. Attention to PEPFAR's history is important as it faces reauthorization in the near future, under a far less compassionate conservative regime.

Why PEPFAR, and why should it be of interest to feminists now? As J. Ann Tickner has argued, feminists have long pushed the field of international relations to seriously consider nonmilitary forms of security, framed more holistically as “human security.” Human security considers economic, structural, and ecological factors of human well-being to be of primary importance in assessing safety and security (Tickner 1997, 624–25). It attends more closely to ordinary, everyday threats to human welfare. HIV/AIDS presents, on its face, one such large-scale, global threat to human security. Human security is also consistent with a practical international relations strategy known as “strategic health diplomacy” that has been used to argue in favor of PEPFAR. Strategic health diplomacy seeks to increase global security by combating illness and diseases that might otherwise prove politically destabilizing in future (Daschle and Frist 2015).

PEPFAR, introduced in an era of “compassionate conservatism,” seemed in principle to absorb the concerns of both human security and strategic health diplomacy. Made popular by George W. Bush, compassionate conservatism blended fiscal conservatism with a reliance on and support for churches and conservative faith-based organizations that confronted “the suffering that remains” in the wake of fiscal conservatism (Bush 1999). As such, this meant empowering socially conservative faith-based organizations to confront great social problems (Turek 2014). As will be seen, although compassion may have been salutary, the attempt to endow socially conservative faith-based organizations with special powers to combat AIDS led to a somewhat incoherent policy. In recent years, however, a balance has begun to emerge focused more on evidence-based practices to combat HIV/AIDS. And yet, as PEPFAR approaches its next reauthorization in the near future, a new conservative age is emerging under the banner of “America First” that is no longer compassionate but indifferent to the plight of distant (and near) others. America First is the official title of Donald Trump's foreign policy, which focuses on the threat of international terrorist groups, promising “peace through strength” through aggressive military operations, rebuilding the military, and prioritizing American interests (White House 2017). Therefore, although PEPFAR has entered its early years as a more progressive policy, its future is uncertain. All those concerned with human security, or even the more instrumental strategic health diplomacy, would do well to pay attention to PEPFAR's fate.

PEPFAR has received a great deal of attention in the sciences and health research, particularly in the health sciences literature, where it has been praised, and debates continue to flourish about questions such as whether AIDS-specific funding is the best way to promote overall public health (e.g., Bendavid et al. 2012; Emanuel 2012). It has also prompted several commentaries among activists and in legal, public health and global health journals, where its positive impact as well as its controversial elements, such as abstinence earmarks and anti-prostitution position, have been discussed (e.g., Berer 2006; Dentzer 2012; Idoko 2012; Masenior and Beyrer 2007; Merson et al. 2012). PEPFAR is also of interest to policy scholars, particularly given HIV's negative relationship to other human development indicators (e.g., life expectancy, education, income); the ostensible threat to geopolitics posed by the destabilizing influence of HIV/AIDS in the global South; its threat to “human security”; and the controversies PEPFAR has generated with its focus on abstinence, fidelity, and anti-prostitution (Dietrich 2007; Fidler 2004; Parkhurst 2012). Yet, compared with the health sciences literature, PEPFAR has received relatively little attention as a foreign policy initiative. This article aims to contribute to this literature by looking closely at how it took shape as a socially conservative policy.

In this article, I begin by briefly contextualizing PEPFAR. Following this, I discuss PEPFAR's theoretical orientation to the Foucauldian notion of biopolitics—a positive, life-supporting use of political power—while holding in tension that same power's destructive potentials as articulated by Achille Mbembe's notion of necropolitics and Judith Butler's notion of precarity. In the second section of the article, I draw on congressional transcripts and the text of PEPFAR itself to establish how the architecture of the early legislation sought to withhold funding from groups that supported sex workers and protected funding to (largely faith-based) groups that promoted abstinence, fidelity, and aftercare for the infected. This practice amounted to a moral casting off of certain “precarious” (Butler 2009, 2016) groups and their consignment to the “death world” (Mbembe 2003) of HIV/AIDS. In the third and final section, I consider the origins of conservatism's interest in HIV/AIDS and its distinction of “innocent” victims in the allocation of funding to properly self-regulating groups.

CALLED TO ACTION: THE EMERGENCE OF PEPFAR

Announced during President George W. Bush's 2003 State of the Union address, PEPFAR signaled a major turning point in U.S. policy toward AIDS in Africa, with a mandate to save millions of lives. In marked contrast to Bush's policies related to the “war on terror” and enhanced homeland security, PEPFAR has always seemed an unqualified humanitarian intervention and evidence of Bush's “compassionate conservatism” (Donnelly 2012, 1392). Passed in 2003, PEPFAR initially allocated $15 billion to AIDS relief, the largest sum of money ever dedicated by one country to the eradication of a single disease. The amount has steadily increased since, with more than US$70 billion contributed by the United States to combating the disease from fiscal years 2004 to 2017 (USPEPFAR 2016). Targeting nations particularly hard struck by and ill equipped to remedy the pandemic, the bulk of initial PEPFAR funds were directed toward 15 primarily African nations: Botswana, Côte d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and Zambia. PEPFAR has since expanded beyond its initial focus countries and, along with the Global Fund to Fight AIDS, Tuberculosis and Malaria, is now credited with significantly contributing to the steady decrease in HIV-related deaths every year since 2005 (Global Fund 2016). According to PEPFAR's latest global results, in at least three countries, the epidemic is “becoming controlled,” and nearly 11.5 million people are receiving anti-retroviral treatment (USPEPFAR 2016).

At the same time that it disbursed historic amounts of public funds to address the AIDS pandemic as a key component of U.S. foreign policy, for its first 10 years, PEPFAR also promulgated sexual abstinence as a fundamental means of HIV/AIDS prevention abroad and anti-prostitution as a pillar of the policy. In what follows, I draw attention to PEPFAR as a mode of sexual regulation. I demonstrate how the disavowal of sex workers and a “conscience clause” in the PEPFAR legislation worked together from 2003 to 2013 to reserve funds for socially conservative groups whose work does not embrace the “multisectoral” approach deemed best practice for AIDS prevention. First, I turn to a theoretical framing of this discussion of PEPFAR in which the relationship between biopolitics, necropolitics, and precarity can be clearly articulated in their relationship to the anti-prostitution pledge and the conscience clause.

BIOPOLITICS, NECROPOLITICS, AND PRECARITY: FRAMEWORKS FOR UNDERSTANDING PEPFAR

As a large-scale effort to create an AIDS-free generation (i.e., to eradicate HIV/AIDS), PEPFAR manifests the Foucauldian notion of the governmental state. Unlike the territorial monarchies that preceded it and relied on the disciplining of individual bodies operating in the interests of the sovereign state (i.e., through schools, factories, militaries), the governmental state is concerned with the well-being of the population (Foucault 1991, 96, 104). Population is more than the sum of its parts: “It is a new body, a multiple body, a body with so many heads that, while they might not be infinite in number, cannot necessarily be counted” (Foucault 2003, 245). The governmental state is concerned with regularizing the condition of the population so as to optimize life: “The mortality rate has to be modified or lowered; life expectancy has to be increased; the birth rate has to be stimulated. And most important of all, regulatory mechanisms must be established to establish an equilibrium, maintain an average, establish a sort of homeostasis, and compensate for variations within this general population … so as to optimize a state of life” (Foucault 2003, 246–47). Foucault labeled this endeavor to regulate, or to regularize life and death at the level of the population, “biopolitics” (Foucault 1997, 73; Foucault 2003, 243).

PEPFAR is a manifestation of biopolitics on at least two levels, the first concerned with the health and longevity of global populations and the second related to the safety and security of Western populations that may be destabilized by HIV/AIDS. First, as a global health measure, PEPFAR is an intervention aimed at public health and hygiene (abstinence, condom use) and the reduction of morbidity and mortality (care for AIDS patients, prevention of mother-to-child transmission, access to anti-retroviral therapy). However, biopolitics is not merely the positive use of power to regularize populations as part of good governance (the “right disposition” of people and things) (Foucault 1991, 93–94). Such interventions ultimately operate in tandem with the state's interest in sustaining and preserving its own power. We also find this second element of biopolitics in PEPFAR.

Concerned with HIV/AIDS as a brewing threat to American security, legislators debating the merits of PEPFAR often cite the links between HIV/AIDS, a generation of orphans, poverty, and desperation, on the one hand, and economic collapse, radicalism, and terrorism, on the other. For example, then-representative Mike Pence (R-IN) once commented, “If not addressed, this plague will continue to undermine the stability of nations throughout the third world, leaving behind collapsing economies, tragedy, and desperation, which we all know is a breeding ground for extremist violence and terrorism.”² U.S. legislators see combating HIV/AIDS as a prophylactic against contagious political destabilization that could otherwise affect the United States negatively in the future. This concept of combating future political instability through public health campaigns is known as “strategic health diplomacy” (Daschle and Frist 2015).

Unlike the state's management of the population within its own territory, which is Foucault's focus, HIV/AIDS is an example of a global threat that does not respect borders or nationality. Illness running rampant in one region can spread in the form of epidemic or cause secondary political destabilization elsewhere. Contemporary states, therefore, must make population-level interventions on a global scale. In the case of HIV/AIDS, this might include such initiatives as campaigns encouraging citizens to get tested for HIV and to practice safer sex, funding for treatment and/or care for AIDS patients, and needle exchange programs. However, as Foucault is careful to note, the governmental state, which acts at the level of the population, does not replace the disciplinary state, which acts at the level of individual bodies to produce self-governing subjects who will choose risk-minimizing behaviors. The ideal of the self-governing subject is embedded in the neoliberal ideology of the rational, efficient subject who, through self-mastery, aids in the maintenance of a lean, efficient state (Lemke 2001, 203).

Indeed, governmentality is the point of contact “between the technologies of domination of others and those of the self” (Foucault 1988, 19). That is to say, the governmental state relies on individual techniques of self-mastery and self-knowledge (Foucault 1997, 87) (e.g., open communication between partners, disclosure of seropositive status, sexual abstinence or chastity in marriage, condom use) in addition to population-level initiatives. Therefore, alongside biopolitics’ productive efforts, the hard hand of discipline remains present in the power to let die (Foucault 2003, 254). That is to say, biopolitics as a technique involves exclusion, banishment, and exile of the noncompliant or nonconforming alongside its positive, lifesaving endeavors. In PEPFAR's case, this initially meant the attempted exclusion of sex workers and those not sexually abstinent, which I will describe in subsequent sections.

Sexuality occupies a special place in Foucault's theory of governmentality. While governmentality marks the intersection of self-government and the government of others, sexuality marks the meeting place of the body and the population (Foucault 2003, 252). Therefore, it is an important field of intervention requiring self-government and government of others (governmentality). Under normal circumstances, we can expect sexuality to be heavily scrutinized and subject to intense regulatory efforts. In the case of HIV/AIDS, which is in large part sexually transmitted, even more so. However, sexuality presents a puzzle—as a target of disciplinary power, individual practitioners of “irregular sexuality” are sanctioned by the illnesses that (are allowed to) infect them (Foucault 2003, 252). As I describe later, this disciplinary tactic of “letting die” was operational in the anti-prostitution pledge and in attempts to protect funding for groups that promoted abstinence and post-infection care as their primary (or only) outreach. However, as a target of biopolitics, as in PEPFAR, sexuality, even taboo sexuality must be the object of life-promoting power if HIV/AIDS is to be vanquished at the level of the population—which was the aim of the policy.

How can the disciplinary move of letting individuals and groups die coexist with the large-scale, population-level objective of eradicating a disease? The two appear inherently contradictory. Letting die means abandoning certain individuals or groups of individuals to a fate in which they are excluded from prevention efforts or are untreated. It also leaves the chain of infection intact, thus undermining attempts to eradicate the disease from the population and lessen infection rates while improving life expectancy. Foucault resolves this puzzle when he comments that medicine is a particular power-knowledge that can be applied both to the body and to the population, having both disciplinary and regulatory effects. In other words, discipline and biopolitics intersect to create norms (“the normalizing society”) by targeting the individual and the population in quite different ways, thus “succeed[ing] in covering the whole surface that lies between the organic and the biological, between body and population” (Foucault 2003, 253). As PEPFAR is a medical intervention (i.e., dealing with the prevention and treatment of disease), Foucault's notions of discipline and biopolitics are clearly operational, attempting to produce self-regulating subjects while making large-scale interventions to combat the disease. However, in Foucault's analysis, power's destructive potentials seem relatively marginal when compared with its life-promoting potentials. Placing biopolitics in the global, post-colonial context, where power's destructive side has been more prominent, subsequent scholars have expanded the analysis of modern-day destructive political power. Here I turn to Achille Mbembe and Judith Butler for an expanded understanding of Foucault's biopolitics in the face of PEPFAR.

Achille Mbembe contests Foucault's interpretation of contemporary sovereign power as primarily productive and life-promoting. Stating instead that politics is the “work of death” (Mbembe 2003, 16), he reclaims a notion of politics as primarily violent and warlike and draws attention to the creation of “death-worlds” as a dominant political rationale. Foucault treats abandonment or neglect either as a disciplinary measure working to produce docile bodies, complimentary to biopolitcs’ population-level projects (as in the case of “irregular” sexuality) or as the limit of biopolitics’ reach. However, Mbembe has a more robust analysis of the destruction of one's other. “Necropolitics” designates those endeavors that revolve around the “subjugation of life to the power of death” (Mbembe 2003, 39). Unlike Foucault, Mbembe treats death as far too important to be subsumed under biopolitics as that which marks its limit. Instead, he recenters death and violence in modern politics as the work of destroying one's Other (Mbembe 2003, 18) in order to secure one's own life. As Mbembe demonstrates in his own discussion of late modern colonial occupation in Palestine, disciplinary, biopolitical, and necropolitical regimes work in tandem (2003, 25–29). Mbembe provides more insight into the operations of power in the global context and a post-colonial reading of power. As he describes it, colonial incursions establish their sovereignty via their capacity to define “who matters and who does not, who is disposable and who is not” (Mbembe 2003, 27). Foucault and Mbembe agree that insider and outsider status turn largely on race. Indeed, for Foucault, racism is used to justify the limits of biopower. Similarly exposing biopolitics’ dark side, Judith Butler moves beyond both Foucault and Mbembe to reveal how these incursions are sexed and gendered as well.

Like Mbembe, Butler has clarified the uneven operation of biopolitics by pointing out that it is entirely contingent upon producing some bodies as worthy of compassion, and therefore as grievable, and other bodies as ungrievable, or “lose-able” (Butler 2016, 31). The latter's lives become characterized by “precarity,” since they are both shut out from access to the substance of their needs and not grieved when their lives are lost. In Mbembe's terms, they are disposable. Such was the case with the LGBTQ (lesbian, gay, bisexual, transgender, and queer) community at the height of the HIV/AIDS epidemic, and in sub-Saharan Africa, which was virtually shut out in the early years of anti-retroviral drugs (Butler 2009). Neither LGBTQ persons nor Africans were understood as worthy of compassion, and indeed, both were understood as being morally responsible for their illness. Similarly, in the case of PEPFAR, the privileging of abstinence and treatment and the explicitly “abolitionist” stance of the policy during its first decade created a condition of precarity for sex workers and the sexually nonabstinent.³ The condition of precarity “designates that politically induced condition in which certain populations suffer from failing social and economic networks of support and become differentially exposed to injury, violence, and death” (Butler 2016, 25). Butler takes up the Foucauldian theme of the normalizing society and its exiles but extends beyond race to gender and sexual norms:

[T]o be a subject at all requires first complying with certain norms that govern recognition that make a person recognizable. And so, non-compliance calls into question the viability of one's life, the ontological conditions of one's persistence. We think of subjects as the kind of beings who ask for recognition in the law or in political life; but perhaps the more important issue is how the terms of recognition—and here was [sic] can include a number of gender and sexual norms—condition in advance who will count as a subject, and who will not. So it is, I would suggest, on the basis of this question, who counts as a subject and who does not, that performativity becomes linked with precarity. The performativity of gender has everything to do with who counts as a life, who can be read or understood as a living being, and who lives, or tries to live, on the far side of established modes of intelligibility. (Butler 2009, iv)

In other words, those who do not play by the rules by performing the sexual, gendered (and other) identities prescribed for them are eligible for neglect or violent casting off, unworthy of care or even grief. Butler and Mbembe both recognize that the power to define the norm is the power to define who is a political subject. The global North continues to flex its muscles by establishing some of these boundaries through its foreign aid policy. In an effort to create norms designating a “more moral” way of life in the global periphery, the United States has relied on disciplinary, necropolitical tactics in equal measure to biopolitics. Post-colonial scholars frequently remind us that these tactics are not new but represent a continuity with colonial practices. Further, an overemphasis on biopolitics as life sustaining frequently obscures the necropolitics that is its complement.

In the name of development, aid, or simply progress, colonialism in its varied guises has required that local people “cover their bodies, subject their bodies to hygiene, fill their bodies with western knowledge, move their bodies to different lands … Bodies that seemed too ‘other’ to fit on the approved colonized/development line could suffer assault and death” (Sylvester 2006, 68). In the post-colonial context, disciplinary measures aimed at bodies persist. However, there is a marked tendency among donor countries to engage in what Uma Narayan (2005) has called the “politics of rescue” and the “politics of forgetting.” The politics of rescue casts Westerners as a positive force in the global South, while the politics of forgetting allows them to forget the multiple and various ways that they are complicit in the problems they identify there. Expressions of cosmopolitan solidarity coexist with the “culturalization” of (i.e., attributing to culture) various pervasive social ills such as violence, poverty, and rape (Razack 2004). When social problems in the global South are treated as “cultural problems,” Western attention is diverted from structural forces that contribute to and exacerbate these problems. The global South is imagined as a place steeped in tradition and culture (the West is unmarked in this regard) while deflecting attention from structural factors in which the West is complicit.

In the case of HIV/AIDS, the focus on African abstinence as a needed moral-cultural shift seemed to assume that Africans are somehow more promiscuous than Americans. This ignored the ways in which states within the global North and multinational pharmaceutical companies hampered broad access to affordable anti-retroviral drugs (‘t Hoen 2002). It also ignored the fact that, initially, residents of the global North largely turned a blind eye to the problem. Moving back further on the historical timeline, it ignored the role of European redistribution of African populations in order to build colonial infrastructure (e.g., railways) and past errors in Western public health schemes (such as reusing vaccination needles), which were both factors that contributed to the virus taking on epidemic proportions (Pépin 2011). It is easy to consider only biopolitics—PEPFAR's positive manifestation of power, given the millions of lives that have benefited from it. However, traces of the colonial civilizing mission and racist assumptions about the backwardness of African cultures emerge when we consider those cast off by its early sexual regulation clauses. Keeping this in mind, I turn to a consideration of the two clauses that constituted the necropolitical aspect of PEPFAR, threatening to undermine the population-level, biopolitical project of sustaining life.

CONDITIONAL CURATIVES: THE ANTI-PROSTITUTION PLEDGE AND THE CONSCIENCE CLAUSE

At the heart of PEPFAR's first instantiation were two amendments, both introduced by Representative Chris Smith (R-NJ), which are notable because together they provide evidence of the policy's early preoccupation with sexual regulation. These are the anti-prostitution pledge and the conscience clause. Smith proposed the first of these amendments in the Committee on International Relations on April 7, 2003, indicating an abolitionist perspective toward sex work. Smith's amendment passed 24–22 and stipulated that “[n]o funds made available to carry out this Act, or any amendment made by this Act, may be used to promote or advocate the legalization or practice of prostitution or sex trafficking” and that “[n]o funds made available to carry out this Act, or any amendment made by this Act, may be used to provide assistance to any group or organization that does not have a policy explicitly opposing prostitution and sex trafficking.”⁴ Funding recipients were required to sign a declaration that the activities of their organization were consistent with these provisions. This restriction initially applied to all the activities of the organization in question, including those not funded by PEPFAR. Accordingly, the restriction applied to organizations’ use of private funds that were unrelated to PEPFAR.^{5, 6}

The second amendment of note was made in Congress less than one month later, on May 1, 2003. It is striking when juxtaposed with the former, which kept funding away from groups that assist, or at least do not explicitly oppose, sex workers. The second amendment, a “conscience clause,” protected funding to groups that rejected the “multisectoral” approach to fighting AIDS favored by the medical community, which integrates prevention (including abstinence, faithfulness, and condom use—the “ABC” approach) alongside treatment and care (Sepúlveda Amor 2007, 135; see also Dietrich 2007, 287). Also rather striking and facilitating such juxtaposition is that these two amendments appeared back to back in the text of PEPFAR. Smith carefully delimited eligibility for funding, moving beyond preexisting language that protected organizations from having to use all three prongs of the government's official ABC approach to combating HIV/AIDS:

An organization that is otherwise eligible to receive assistance … to prevent, treat, or monitor HIV/AIDS shall not be required, as a condition of receiving the assistance, to endorse or utilize a multisectoral approach to combatting HIV/AIDS, or to endorse, utilize, or participate in a prevention method or treatment program to which the organization has a religious or moral objection. ⁷

This amendment protected the eligibility of groups that only endorsed abstinence education, or post-infection treatment of HIV/AIDS. The anti-prostitution pledge, on the other hand, limited and prevented funding to groups whose (ethical) positions were at odds with a protected ideological stance (anti-prostitution) from obtaining funding. While the conscience clause may at first glance seem to protect any moral position, the existence of the anti-prostitution pledge revealed it had a different purpose. While the anti-prostitution pledge was an injunction against action (assisting or promoting sex work), the conscience clause was a protection from being compelled to act. Those in the latter category are not doing anything wrong in the first place—they simply must be protected against taking any action with which they disagree. This seems fair, provided the services they deliver are making significant contributions to combatting HIV/AIDS. That they are doing so is not typically contested. However, the fact that moral duty very often requires one to take action and not merely to refrain from acting means that those for whom the active component of assisting sex workers and refusing to take a stance against them is an ethical position would find that their conscience was not protected. Indeed, it was attacked, unlike those who opposed condoms and sexual education on moral grounds. Taken together, these two clauses gave with one hand and took with the other, consigning vulnerable populations such as sex workers to the risk of illness and death—precarity.

A further concern is that, beyond merely protecting the inaction of certain groups on the grounds of conscience, the conscience clause appears to protect approaches that actively undermine the third branch of the multisectoral approach (condoms), when all three branches of prevention have been deemed crucial. The antagonism between an abstinence-only (or even primarily) approach and condom use has raised concerns about the spreading of misinformation about condom use. Raymond Copson has argued that the U.S. policy has encouraged elements hostile to condoms, noting that the first lady of Uganda, Janet Museveni, whose National Youth Forum received PEPFAR funds, suggested that condoms lead to promiscuity and cause genital warts (Copson 2007, 61). This very concern that the conscience clause only protects one ethical stance was at the heart of debate over Smith's conscience clause, as is clear in this exchange between Representatives Barbara Lee (D-CA) and Chris Smith:

Lee: Now, it seems to me, quite frankly, that social conservatives are looking at a way to carve out a specific exemption. All of us support faith-based organizations, but it looks like one group of individuals in this country wants to carve out for religious organizations a specific exemption … It appears now that this amendment would give an organization the ability to affirmatively tell those suffering and dying of AIDS not to use one method over another. This could be deadly.

Smith: I wish the gentlewoman had not gone the route of saying there is another motive here … [W]e can fund condoms till the cows come home in this bill; but we are saying there are providers among the best an [sic] earth—the CRS [Catholic Relief Services]—who are deeply respected in the community, with access to the at risk populations, yet who would not get funding without real conscience clause protection. Catholic and Muslim groups are the ones we are mostly talking about, and it seems to me that it is counterproductive in the extreme to everything we are trying to do here—to prevent their full participation.⁸

It is not clear how Smith's anti-prostitution amendment by contrast, which prevents the full participation of a range of effective groups from states to nongovernmental organizations, can be defended from the same charge of being counterproductive. In 2005, Brazil turned down US$40 million in U.S. Agency for International Development (USAID) funds in protest against PEPFAR's stance on prostitution, “in order to preserve its autonomy on issues related to HIV/AIDS as well as ethical and human rights principles,” according to Brazil's HIV/AIDS program (quoted in Pimenta et al. 2009, 17). Programs in Brazil targeting sex workers had “tangible effects regarding knowledge about HIV risks, condom use and, indirectly, the need for systematic sexual healthcare and HIV/AIDS treatment” (Pimenta et al. 2009, 50). More work documenting the effects of these PEPFAR restrictions on the ground would be beneficial. One source noted in 2010 that the exclusionary policies of PEPFAR at that time meant no support for needle exchange programs, no anti-retroviral treatment targeted at drug users, heightened public scorn for sex workers, high infection rates in men who have sex with men and transgender individuals, to name but a few consequences in practice (Evertz 2010, 13–17).

Returning to Butler's concept of precarity, although the two amendments were cast in inclusive language, they had the effect of differentially exposing some populations to illness, suffering, and death (Butler 2016, 25). Consider, for example, a comment by Representative Joe Pitts (R-PA): “We should have the best organizations working within our overall plan on parts of the plan that they do best.” And again, “It is meant to make sure that we do not arbitrarily disqualify any organization from one part of our strategy because they do not participate in another.”⁹ The outcome of Smith's two amendments, however, was to protect the agenda of socially conservative organizations and their ability to obtain funding for their mission of abstinence education and care for the infected while limiting aid to effective programs that embrace condoms, reach out to sex workers, and do a large part of the work of prevention.¹⁰

The conscience clause amendment buttressed existing language in the bill that protected the funding eligibility of groups that did not endorse a multisectoral approach. Representative Tom Lantos (D-CA) challenged Smith on the inclusion of what he considered unnecessarily airtight protections, fearing—like Barbara Lee—that it would be used to undermine condom promotion and discourage referral to other organizations providing other types of AIDS prevention. For this reason, Lantos requested that Smith add the following provision to his conscience clause, in order to prevent some groups from interfering with forms of intervention that they disagree with: “Except that such organization may not undermine interventions that it does not endorse, utilize or participate in.” Smith's reply yielded no ground: “The problem is the word ‘undermine.’ If a group opposes a certain type of prevention such as condom use that could be construed in the eyes of someone who is making a grant or letting a grant, that organization should not get funded. The proposed Lantos language nullifies any conscience clause so I must reject it.”¹¹ Here again, it is necessary to contrast the conscience clause amendment with the anti-prostitution amendment.

While Smith was intent on clarity in order to protect a particular version of religious sensibilities, the anti-prostitution oath was vague on its face, and implementation was plagued by lack of clarity. In December 2010, Assistant U.S. Attorney Ben Torrance was asked by judges in the U.S. Court of Appeals “whether supporting the unionization of prostitutes or advocating to ease government restrictions targeting prostitutes were allowed under the pledge.” Torrance failed to clarify, replying, “It depends. There are shades of grey. This is a judgment for Congress, not for the agency receiving the funds” (quoted in Doyle 2011). Some organizations refused funding because of a lack of certainty as to whether funding would compromise their missions or, much worse, require them to abandon programs targeting sex workers for fear of losing funding (Dietrich 2007, 288; Ditmore and Allman 2013; Doyle 2011).

In sum, though proponents of the conscience clause defended it in terms of giving all organizations a fair chance, when observed in relation to the anti-prostitution oath and considered in the context of its practical application, the conscience clause served as a tool for bending policy to the socially conservative purposes of sexual regulation while sealing it off hermetically from the influence of alternate views. At the most basic level, the effect of protecting funding to abstinence-only and anti-prostitution groups is to reserve funding for assistance to those who meet conservative Christian notions of moral entitlement—those who are “innocent” victims of HIV/AIDS. Here we see necropolitics at play—the creation of death-worlds for those who do not self-discipline along the lines set by the normalizing society.

The conscience clause was retained and, indeed, strengthened when PEPFAR was reauthorized in 2008. The original text provided that in order to receive funding, organizations were not required to endorse or utilize a multisectoral approach or to endorse or participate in programs to which they had moral or religious objections. The new language added that they need not make referrals to or become integrated with any programs to which they had moral and religious objections, and it stated explicitly that they may not be discriminated against in the allocation of funding. Initial abstinence earmarks were also done away with.¹² In their place, there remains a requirement that if less than 50% of an organization's funding is devoted to programs promoting sexual abstinence, monogamy, delayed sexual debut, and faithfulness, they must submit a report to Congress.¹³ Thus, abstinence-related activities continue to hold a place of privilege among U.S. global anti-AIDS initiatives. While the anti-prostitution pledge was retained in PEPFAR's 2008 reauthorization, the U.S. Supreme Court struck it down in 2013.

One might conclude from all of this that PEPFAR's current incarnation is an improved but still ambivalent one. In December 2013, President Barack Obama signed the PEPFAR Stewardship and Oversight Act of 2013, which extended the provisions of the 2008 reauthorization through 2018. PEPFAR without the anti-prostitution pledge is therefore still in its early years, and with a strong conscience clause in place and a new and unpredictable political landscape on the horizon, the lessons of the recent past may yet prove instructive. In the final section, to which I now turn, I consider how “compassionate conservatism” came to consider AIDS as a compelling moral issue and how it framed worthy victims. I conclude this section by emphasizing the current shift away from compassionate conservatism, and the uncertain future for PEPFAR, both as a reflection of American compassion and as a form of strategic health diplomacy.

COMPASSIONATE CONSERVATISM AND ITS WORTHY VICTIMS

Religious conservatives can be credited with much of the governmental action taken on HIV/AIDS, a hallmark of compassionate conservatism, in the United States over the past two decades. Conservative senator Jesse Helms (R-NC) was instrumental in securing a $500 million program to fight AIDS by treating HIV-infected African women in 2002. It was conservative president George W. Bush who set PEPFAR in motion by commissioning Dr. Anthony Fauci, head of the U.S. National Institute of Allergy and Infectious Diseases, to develop an initial PEPFAR plan (Donnelly 2012, 1389–90). Instrumental in setting the political agenda of PEPFAR, conservative representative Chris Smith introduced the pillars of sexual regulation that became its central focus in early years. And yet, HIV/AIDS in Africa was not previously a concern among most conservatives, or indeed among most residents of the global North. How can we account for this about-face? Understanding the origins of conservative religious interest on this issue can help make sense of the relationship between the pillars of sexual regulation within PEPFAR, abstinence, and the anti-prostitution pledge and the identification of morally “worthy” victims.

Holly Burkhalter (2004) identifies a positive “turning point” in global HIV/AIDS prevention when conservative Christians adopted the issue as their own in 2002. She claims the definitive moment was the first International Christian Conference on HIV/AIDS in Washington, DC, titled “Prescription for Hope.” Attended by 800 evangelical Protestant and Catholic leaders, with “state-of-the-art visuals, gospel choruses, and heartbreaking testimony from African ministers and health workers,” the event was a clarion call to this community to adopt HIV/AIDS eradication—particularly treatment—for “innocent victims,” the sick and the dying as a moral imperative (Burkhalter 2004). Burkhalter notes that Senator Helms, who was at the conference and confessed his shame at having done little to helps AIDS sufferers, led the charge, focusing on heterosexual and mother-to-child transmission and “innocent” victims. Helms published an op-ed promising to secure $500 million for mother-to-child transmission (Helms 2002), a promise on which he subsequently made good and which was announced by President Bush, who acknowledged Helms's leadership on HIV/AIDS, in June 2002.

Helms's sudden interest in AIDS and his professed shame at having done little to combat it are both noteworthy and puzzling, as it was Helms who proposed an infamous U.S. travel ban on migrants with AIDS, which lasted from the mid-1980s until 2010.¹⁴ Helms's travel ban added AIDS to the list of “loathsome” diseases used as grounds for refusing entry to migrants. Instead of focusing on those who engaged in behaviors that posed health risks, implementation of this “health” measure focused on migrants from sub-Saharan Africa and Haiti and on homosexuals. It resulted in HIV-positive Haitian migrants sometimes being detained/contained for years with their families at Guantánamo Bay (Fairchild and Tynan 1994, 2015). Nevertheless, Bush was explicitly building on the new surge of interest highlighted by Helms's work in 2002 when he announced PEPFAR in his 2003 State of the Union address: “a work of mercy beyond all current international efforts to help the people of Africa” (Burkhalter 2004; Donnelly 2012).

Early on, the conservative focus on combatting HIV/AIDS addressed itself to “innocent” AIDS victims through the focus on mother-to-child transmission and post-infection treatment, even as the U.S. travel ban on migrants remained in place until 2010 and sex workers in some U.S. cities were, and are still, discouraged by law enforcement from carrying condoms (Human Rights Watch 2012).¹⁵ Comments along the way by legislators, which focused on the civilizing component of anti-HIV/AIDS efforts, drew further distinctions between innocent and culpable AIDS sufferers.

Legislators often framed the campaign against HIV/AIDS in terms of charity and a contemporary civilizing mission. Representative Rick Renzi (R-AZ), arguing in favor of the conscience clause, located its value precisely in its civilizing role: “This amendment makes necessary distinctions which ensure that faith-based organizations can continue to educate and change people's hearts, minds, and souls towards a more moral way of life.”¹⁶ That is to say, religious groups that seek to incorporate “deviants” and unmarried sexual partners into a traditional family format by insisting on reserving sexual activity (and most AIDS funding) to married individuals should be supported for working to enlighten recipients of U.S. funding. In this framing, explanation for the prevalence of HIV/AIDS in certain communities looms dangerously close to claims that AIDS is a disease of the morally defective, representing God's punishment for immoral or immoderate behavior. This seems to justify their abandonment to a life of precarity and the death-world of HIV/AIDS. Therefore, attempts to improve the morals of foreign peoples by bringing them into line with the nuclear family ideal is wrongheadedly linked with ending the spread of disease.

In opposing Pitt's amendment, Representative Nita Lowey (D-NY) complicated the issue by arguing that even lifestyles that are morally acceptable on socially conservative terms can leave their practitioners vulnerable to infection:

Many women in Africa infected with HIV were abstinent before marriage, and monogamous in it, and yet still they are wasting away from AIDS. … Again, she's married, she's faithful … she's dying. We can have it all—we can have monogamy and condoms, we can have abstinence before marriage and access to condoms too. It's just a matter of deciding that saving lives matters more than how it's done.¹⁷

As another scholar summarizes the issue, “Because abstinence does not protect married women, who need to learn to protect themselves, workers in the field are often infuriated by the suggestion that abstinence education is the key to AIDS prevention. Furthermore, monogamy and fidelity are not an issue for married women or babies who become infected. Nor do many sex workers face realistic options” (Smallman 2008, 18). Like this comment, Lowey's remarks bring into sharp relief the important distinction and, indeed, disjuncture between goals of “civilizing” or encouraging the putative moral and social evolution of a people (individual behavior-discipline) and the aim of eradicating a devastating disease (population-biopolitics).

In the face of a public health campaign, particularly a campaign against an infectious disease, success demands that the state cannot sort populations into categories of the disposable deviant and the morally deserving. Otherwise, it becomes an “anti-public health campaign” (Berer 2006, 6; emphasis added). Sex workers are often on the front lines of sexual health campaigns as activists and peer educators and are themselves in need of services and support (Masenior and Beyrer 2007, 1159). To exclude them, or intravenous drug users, or the sexually active yet unmarried, from health campaigns is both unethical and unwise. Biopolitics is the life-sustaining manifestation of power, targeted at populations. To combat the disease, the state cannot simultaneously combat individuals who are otherwise capable allies against it. HIV/AIDS prevention initiatives require the inclusion of (among others) sex workers and the sexually promiscuous for the success of their initiatives. Yet notions associated with the moral uplift of the community and the goal of an abstinent Africa press the state toward policing practices that marginalize and place at risk a group whose inclusion is required for the success of its policies.

Lisa E. Sanchez's illuminating work on the sex worker as “excluded exclusion” helps clarify the power dynamics in the state's self-defeating marginalization of sex workers both domestically and in foreign policy. Comparing the prostitute to Giorgio Agamben's (1998) homo sacer, Sanchez (2004) notes that homo sacer is the figure of the male outlaw, an included exclusion who is displaced but who has the possibility of return. He can be redeemed and move from outside to inside, reclaiming his place in the community. The prostitute, by contrast, is the excluded exclusion, for whom there is no possibility of reintegration, and whose eternal externality marks the space outside the community—that space to which homo sacer may be exiled but from where he may return. To illustrate her point, Sanchez discusses the “prostitute-free zone,” a policy of reverse-zoning adopted in many U.S. cities, according to which sex workers are banned from entering a particular area of the city. Creation of prostitution-free zones suspends the citizen's right to free movement and choice of domicile. It also inhibits sex workers’ ability to perform other, legal tasks unrelated to sex work, tasks that are not denied to other citizens. Thus, like the anti-prostitution pledge and indeed the insistence on abstinence, the prostitute-free zone makes clear the increasingly blurred boundary of biopolitics and necropolitics in a policy that protects the moral integrity of some members of the community at the cost of the utter exclusion, erasure, and banishment enacted on the bodies of sex workers (or drug users or the unmarried), even at moments when they are acting wholly within the bounds of law. Failing to perform sexual and gender norms, they embody Butler's notion of precarity—vulnerable to danger and death. Still, the image of an innocent victim evokes an image of a compassionate and generous American nation and helps bolster U.S. moral capital at home and abroad, thus also ostensibly increasing its security.

In addition to making a moral argument in favor of anti-HIV/AIDS funding abroad, legislators sometimes invoked human rights as a means of making explicit the link between assisting AIDS-ravaged communities and the founding ideals of the American nation. For example, representative Michael Enzi (R-WY) soliloquized,

Our Founding Fathers were never more inspirational than when they wrote that our Creator has endowed us with certain unalienable rights — and among these are life, liberty and the pursuit of happiness. Swift passage of this bill will again show the world that these aren't just words on a piece of paper. Swift passage will again show that these words apply to every citizen of every country—not just our own.¹⁸

Similarly, Mike Pence stated that “[t]he greatest of all human rights is the right to live. America is a Nation of great wealth, wealth of resources, but more importantly, a wealth of compassion.”¹⁹ Here the “right” to life of those communities ravaged by AIDS is linked to the goodwill of the American people through reference to their compassion rather than to particular moral or legal entitlements to lifesaving treatment. The point of both references to rights is not merely the assertion of human rights itself, but rather a statement about what it means to be American (compassionate, freedom loving, life affirming). This discourse of American compassion and America as a rights-respecting (and advocating) nation already has been historically complicated in the face of the precarity and necropolitics that constituted the other side of AIDS-prevention in early years—that is, in the plight of those subjects who are not properly “self-regulating” and therefore left vulnerable to the death-world of AIDS.

With the elimination of the anti-prostitution pledge and the move toward evidence-based interventions, PEPFAR in recent years has moved further from the ideological, necropolitical model toward more inclusive and evidence-based strategies. It has gained crucial distance from its socially conservative framers while retaining its power to represent American compassion. However, the discourse of compassion surrounding PEPFAR will become complicated as it confronts the emerging discourse of America First under Donald Trump's presidency and a move away from compassionate conservatism. It is not yet clear what the future holds for strategic health diplomacy. As John W. Dietrich forewarned as early as 2007, “Positioning PEPFAR as part of a U.S. moral tradition is likely to have rhetorical appeal to future administrations, but that does not guarantee continued funding and attention. It is less certain whether the religious arguments will be utilized by others in the future” (2007, 282). A series of questions circulated by the Trump administration transition team at the State Department in January 2017 queried, “Is PEPFAR worth the massive investment when there are so many security concerns in Africa? Is PEPFAR becoming a massive, international entitlement program?” (Cooper 2017). Seemingly skeptical about foreign assistance, a further question asked, “Why should we spend these funds on Africa when we are suffering here in the U.S.?” (Cooper 2017). Just as PEPFAR has entered its second decade as a historic global health policy and has made some movement toward inclusivity, this seems to signal a potentially drastic departure from America's wealth of compassion, as emphasized by Pence and Enzi.

LESSONS FROM THE RECENT PAST AS PEPFAR CONTEMPLATES ITS FUTURE

In January 2003, President George W. Bush prepared the country for what history would later judge an ill-advised and ill-fated war against Iraq during his State of the Union address. Similar to Trump's America First foreign policy, Bush invoked the threat of terrorism as a justification for his militarized approach to security. Unlike Trump, however, Bush seemed to counterbalance his hawkishness by announcing PEPFAR, thus acknowledging other forms of security beyond militarism: “This nation can lead the world in sparing innocent people from a plague of nature [i.e., AIDS] and this nation is leading the world in confronting and defeating the manmade evil of international terrorism” (Bush 2003). Although plagued in its early years by controversial policies and needing to have wrinkles ironed out, PEPFAR has been improved by many of the critiques leveled at it, becoming a force for positive change globally. It may very well be the only widely acknowledged positive legacy of the George W. Bush presidency. Policy makers should therefore consider how much more effective this human security/strategic diplomacy-oriented policy has been in generating goodwill toward the United States and global well-being, in contrast to the militarized strategy of invasion and war.

When, in May 2017, the president's budget for 2018 was released by the Trump White House, it raised an alarm among the AIDS prevention community by calling for an “$800 million cut to bilateral HIV/AIDS efforts—including PEPFAR—and $225 million cut to the Global Fund [which would] would force PEPFAR to implement a strategy that could result in nearly 300,000 deaths and more than 1.75 million new infections each year” (Ottenhoff, Crawford, and Huie 2017, 3). If such cuts are approved, the progress achieved by PEPFAR thus far risks being lost, and the possibility of ending the epidemic status of HIV/AIDS may slip away. No budget for the 2018 fiscal year has been approved at the time of writing, yet it seems clear that at the moment, the political forecast is a move toward heavy military spending and away from human security and diplomacy. This strategy threatens to repeat Bush's errors, and to discard his one ultimately successful initiative, which has only begun, in recent years, to lose some of its retrogressive fetters, such as abstinence earmarks and the anti-prostitution pledge.

George W. Bush's presidency was marred by the atrocities committed in Iraq and other violent scandals, such as the dismissal of the Geneva Conventions. Despite the obvious animus between Bush and most feminists and progressives, the “compassionate” side of his policy approach, as articulated in PEPFAR (however misguided many have found earlier versions of it), was compatible with the concept of human security, which has been widely embraced by feminist international relations scholars, and with the concept of strategic health diplomacy. The current ideal of America First propounded by Trump flies in the face of the sort of outward-looking concern that Bush articulated when referring to sparing the world of the plague of HIV/AIDS—regardless of whether he did so cynically.

What are the implications of these considerations? For Republicans: if we are to take any lessons from the George W. Bush presidency, there is the likelihood that neither the present nor history will find anything redeeming in the unreservedly hostile and unbalanced militaristic policies of America First. Rather, it will redound to the detriment of the Republican Party, much like the invasion of Iraq, torture, and Central Intelligence Agency black sites did under Bush. Retaining and even strengthening PEPFAR would only reflect well on Trump's administration. Proponents of strategic health diplomacy must confront the possibility that a resurging AIDS crisis will create political instability that will affect the United States and many other countries in future. Most importantly, for those concerned with HIV/AIDS as a global ethical crisis, there is the possibility that the death-world of AIDS will be allowed to claim more lives unnecessarily as military spending increases.

PEPFAR has benefited from bipartisan support over many years and therefore is in some ways a consensus-building issue. It should not be abandoned or cut back. In fact, “the number of people dying from AIDS has been cut by half since its peak in 2005” (Ottenhoff, Crawford, and Huie 2017, 3). This can only be seen in a positive light, for the United States and for the world. Rather, policy makers should continue to support PEPFAR, led in their vision by the needs of the populations targeted by the policy, as articulated by those at the grassroots. Conscience clauses should either be abandoned, or better, reframed: first to include a multiplicity of ethical positions as valid moral choices (e.g., choosing not to condemn sex workers is an ethical position; choosing to distribute condoms is an ethical position—but these have not been protected by the conscience clause), and second, any conscience clause should be framed by members of both parties, including members with diverging views. If a conscience clause is only framed by proponents of one particular ethical stance or worldview, it will in all likelihood be bent toward protecting that view alone, rather than conscience in general. Finally, in order to avoid policies that consign marginalized groups to the ravages of illness and death, the question should be seriously posed of every health policy: who will be neglected or harmed if the policy as such is enacted? In short, PEPFAR without the anti-prostitution pledge and abstinence earmarks is only in its early years. However, as the United States enters a new conservative era that threatens to be far less compassionate, and as PEPFAR will face reauthorization or extension within the next two years, it is well worth paying attention to the history of PEPFAR implementation in order to be knowledgeable advocates for its continued advancement as a progressive piece of legislation, reflecting cosmopolitan values, and free of unnecessary policy barriers to funding.