Friday, May 24, 2002
Excellent piece in The New Republic this week about the successful efforts to combat HIV in Uganda. (Unfortunately, the article doesn't appear to be online. Go buy the issue. Heck, subscribe; it's a great magazine.)
Here's the twist: Uganda's efforts have focused predominantly on (a) abstinence before marriage, and (b) marital fidelity. Condoms are almost an afterthought. The results have been to reduce HIV infection rates from on the order of 20% to on the order of 6%. As a collateral benefit, there's been an increase in marriage, particularly among young people. The contrast to other countries that have tried a more prophylactic and less moralistic approach is striking; infection rates continue to rise in countries like Kenya and Botswana that have extensive condom-oriented efforts.
Why is this? The reason appears to be that condom-oriented efforts work only if they are applied essentially universally. If you have a culture of promiscuity, and even a small failure rate with prophylactic use, then you'll continue to see high rates of infection. The assumption among public health types is that changing promiscuous behavior is much harder than getting people to use condoms, and besides, asking people to make different life choices is a taller moral order than asking them to wear what is pitched as a kind of sexual seatbelt. But if you need a 99% success rate with condoms to significantly reduce infection, but only, say, an 80% effectiveness rate with a campaign to reduce promiscuous sexual behavior, that changes the equation. (I'm making these numbers up, by the way.) Moreover, cultural changes are reinforcing. If more people marry rather than having multiple partners, peer pressure will cause others to adjust their behavior to meet the emerging norm. By contrast, condom use is entirely private; no one besides your partner knows if you are failing to meet the norm. (This is the case with adultery as well, of course, but to a lesser extent; adulterers are often found out, and if the social norm is to stigmatize that behavior, a lot of people won't take the risk.)
The guy who wrote the article is not religious, and the people he cites who promote the program aren't either. This is a legitimate public health story, with obvious implications for the debate currently going on in this country vis-a-vis abstinence education, etc.