AIDS Policy in Uganda: Evidence, Ideology, and the Making of an African Success Story by John Kinsman (review)

In AIDS Policy in Uganda: Evidence, Ideology, and the Making of an African Success Story, John Kinsman challenges the common belief that Uganda successfully tackled the HIV/AIDS epidemic and shows how changing ideologies influence policy work. Kinsman describes his anthropological role as both an observer, who relies on key interviews and archival data, and an AIDS researcher in the Masaka Intervention Trial (MIT), who had unique access to key HIV/AIDS policymakers and officials in the Ugandan Ministry of Health. Throughout his text Kinsman applies the anthropological technique of life history analysis to AIDS-control policies. He also clearly outlines the emergence of HIV/AIDS in Uganda and traces the national and international policy responses to it.

One of the main premises of the book is that rather than relying on scientific evidence, Ugandan policymakers based HIV/AIDS prevention and treatment programs on hunches: “There has been an evidence void on critical aspects of AIDS control over the course of the entire epidemic. No conclusive, unambiguous body of evidence actually existed on most of the strategic issues relevant to AIDS control and, as such, a truly evidence-based policy process would therefore not have been possible, irrespective of policy makers’ public statements” (175). For instance, Kinsman shows how influential individuals within international agencies—whom he characterizes as “Big Men”—drove the global scale-up of antiretroviral therapy (ART) based on personal will or hunches; “Dr. Lee and Professor Sachs were just two of a number of other financial and political Big Men who forcefully imposed their will and overrode the doubts of their colleagues and subordinates” (126). Kinsman also shows how one man, a local worker at the Joint Clinical Research Centre, unilaterally decided—without consent initially from the Ugandan Ministry of Health—to import generic ARV drugs. Again, this policy change came about because of the action of one man, not because of scientific evidence or empirical “proof” that ARV therapy was the best way to combat AIDS in Uganda or that it could be sustained in the long term. “History was, in a sense, repeating itself,” he says. “Just as HIV prevention activities had been conducted on a wide scale for many years without any clear evidence of effectiveness[,]… ART rollout had been instigated on the basis of an urgent need to act rather than on a firm foundation of evidence” (132).

One of the strongest areas of the book is Kinsman’s interweaving of archival material and interview data from key AIDS policy actors in Uganda. The comments of these individuals strengthen his conclusions and offer insights into the personal aspects of policy formation. For example, he relies heavily on interviews with Wilson Carswell, a Scottish surgeon who championed AIDS research in Uganda and worked at the Mulago Hospital in Kampala from 1968 to 1987. Kinsman incorporates several long statements from Carwell that illuminate the tension of defining AIDS in Uganda as the same disease that was afflicting homosexual white males in the United States, particularly because it was rampant in southwest Uganda (a key military route). Kinsman also examines the rhetoric of AIDS policy and debunks the myth that the Ugandan government responded wholeheartedly to the crisis with its “ABC” policy—“Abstain, Be faithful, and use Condoms.” Ugandan policymakers did not develop the ABC slogan, and over time Uganda’s official stance changed from “Zero Grazing”—a campaign in 1988–92 against casual sexual activity in which condoms were quietly promoted—to widespread promotion of condoms in 1992–2002, and then to a public policy of abstinence in 2002–5.

While most chapters offer insight into policy formation in relation to HIV/AIDS prevention and ART treatment, a few chapters seem peripheral and could have been incorporated more fully into the author’s analyses. For instance, Kinsman regularly refers to his work...