Approach to HIV/AIDS Research Pays Off for Green

Paul J Nuti
AAA Director of External, International and Government Relations

June 2006 was an exceedingly good month for AAA member Ted (Edward) Green, whose work at the forefront of HIV/AIDS research has garnered wide attention in recent years.

Ted Green, an anthropologist with the administration's ear. Photo courtesy of Ted Green

On June 27, Green made his third of four appearances before Congress, this time testifying before the House Committee on International Relations (Subcommittee on Africa, Global Human Rights & International Operations) on blood supply safety in Africa, particularly in countries with high HIV prevalence rates. Green used the appearance to offer policy recommendations directed at proper screening of blood donors, improved training of medical personnel, and a reduction in the number of unnecessary transfusions. Two days later, Green learned that the John Templeton Foundation had awarded him a $2 million grant—through his employer, the Harvard Center for Population and Development Studies—to extend his research on HIV/AIDS prevention. It is expected he will also oversee a second $2 million Templeton grant to support behavioral research of other scholars, including anthropologists.

Indigenous Prevention Model
This spate of good fortune marks another chapter in Green’s methodical campaign to demonstrate the efficacy of what he calls the Ugandan approach to containing the global spread of HIV/AIDS. For years, Green and his colleague, cultural/medical anthropologist Daniel Halperin at the US Agency for International Development (USAID), have advanced aspects of a behavioral approach to HIV/AIDS prevention premised on inclusion of “risk elimination,” a primary prevention approach that, in Green’s view, marks a paradigm shift away from strategies that have emphasized “risk reduction” only. Green launched a debate in the late 1990s, arguing that the latter approach—favored by the World Bank, the UN and the US government at the time was simply not working. Condoms and drugs, staples of risk reduction, constituted a Western, commodity-driven approach tethered to pharmaceutical interests, the Western medical establishment and other external stakeholders.

In contrast, Green argues for the indigenous model Uganda developed, which combined risk elimination and risk reduction. He has tackled HIV/AIDS prevention with a decidedly anthropological toolkit and orientation. Asked how anthropology has informed his groundbreaking research over the years, Green trots out expressions familiar to the anthropological community and pulled directly from the anthropological lexicon: indigenous worldview, holistic perspective, study up, underdog, non-Western, sustainable and culturally acceptable approach, etc. Indeed, he gives all credit to Africans for developing an effective response to AIDS for other Africans. Green argues that his ability to access indigenous models that influence behavioral norms in places like Uganda—regarded by many as the quintessential proving ground of the new approach—has put him in an optimal position to challenge the conventional wisdom on HIV/AIDS prevention.

Green traces his maverick journey to the epicenter of the global HIV/AIDS policy arena back to 1993 when he drafted a largely ignored memo outlining how Uganda’s home-grown behavioral—as distinct from biomedical approach—to AIDS prevention was working. Acknowledging a creative streak of anger and indignation, Green has long been critical of Western policymakers and institutions that have presided over failed HIV/AIDS prevention interventions, especially in Africa. His unorthodox views, set out most comprehensively in his 2003 volume Rethinking AIDS Prevention, placed Green on a collision course not only with the majority of the HIV/AIDS prevention crowd but with AIDS specialists in the anthropology community as well. Green’s focus on the ABC (Abstain, Be faithful, use Condoms) prevention model, as well as on the importance of the male circumcision factor (he notes anthropologists Priscilla Reining, Robert Bailey and Daniel Halperin have been at the forefront of this parallel paradigm shift) was seen as out of step with what was fashionable in academic anthropology. The ABC model was actually in line with a moralist agenda embraced by the religious right, and, more recently, by the administration of George W Bush, causing its premature rejection by many anthropologists and health professionals, who tend to be as unsympathetic to rightwing policies as Green is himself. It has complicated matters that some rightwing moralists have tried to characterize Uganda’s approach as abstinence-only, a notion Green continuously has to correct.

Despite resistance from some quarters, Green confidently touts the data—that both partner reduction (or partner fidelity) and voluntary male circumcision can reduce HIV prevalence by up to 70%. He predicts that programs promoting at least the former, if not the latter as well, will likely become centerpieces of HIV/AIDS prevention strategies in the future, at least in heterosexually driven epidemics.

Initiating a Paradigm Shift
Green cites as further evidence of the ascendancy of the risk elimination approach two important moves by the US government in recent years: 1) the designation of the Ugandan ABC model as USAID policy in a Dec 2002 cable to all USAID missions; and 2) the enactment of the President’s Emergency Plan for AIDS Relief (PEPFAR), a 5-year $15 billion initiative to combat HIV/AIDS around the world. Ted Green’s fingerprints can be detected in the text of the basic PEPFAR document which contains numerous references to risk elimination as the foundation for prevention, behavior change and the need to incorporate indigenous views/structures into prevention strategies. More recently, in December 2005, the President’s Advisory Council on HIV/AIDS (PACHA), of which Green is a member, issued a report—“Achieving an HIV-Free Generation: Recommendations for a New American HIV Strategy.” Among the recommendations in the “prevention” section of the advisory document for the US president and for the Department of Health and Human Services secretary, is Recommendation 18 which states that “Careful consideration should be given to the evidence that male circumcision reduces the likelihood of HIV transmission.”

Green was invited on a private trip to four African countries with former DHHS Secretary Tommy Thompson, several senators and representatives, the heads of the Global Fund, National Institutes of Health, the Centers for Disease Control, National Institute of Allergy and Infectious Diseases, and UNAIDS; the CEOs of Pfizer and Merk, Ambassadors Randy Tobias and Richard Hollbrooke (the latter the only other Democrat on the trip besides Green, he believes), foundation heads, and other high-level players in Global AIDS. Green found himself able to discuss AIDS issues with these influential people during dinners and in-flight conversations, and he was asked to formally present his ideas and findings to the entire group one evening. Later in Washington, Secretary Thompson invited Green to have an informal one-on-one discussion about what the US should be doing about AIDS.

The Templeton Foundation is the latest player in the HIV/AIDS prevention community to hitch its wagon to Green’s approach—to the tune of $2 million in research funds, the first of an expected $4 million of research support. It took some persuading by the foundation to lure Green, who at first declined the offer, believing that the scope of what Templeton wished to accomplish was beyond Green’s capability (he worried about lack of formal training in public health and in statistics). Eventually, however, Templeton prevailed in convincing Green that an anthropologist with broad experience and a holistic perspective is exactly what is needed to complete the AIDS prevention paradigm shift. Green saw that Templeton recognized the widespread acceptance of the Ugandan ABC approach found in Africa and beyond, even if American and European advisors clung to the high-tech and more expensive medical model. More research and more data could, Green figured, consolidate these gains and lead to replication in other countries globally, especially in the most severely affected countries in sub-Saharan Africa.

In short, Green and his partners at Harvard (anthropologists Daniel Halperin and Katy Moran) will look at dimensions of HIV/AIDS prevention that have not been studied “because of biases in favor of the medical model.” Incidentally, Green fully supports family planning and he has done much work in this area, but he believes that AIDS prevention raises different challenges. Where possible, he will compare the impact of risk reduction-only strategies with the impact of a broader, risk elimination plus risk reduction strategy. He adds that the role of faith-based organizations (FBOs) in HIV/AIDS prevention requires attention, if not only because FBOs operate many of the health facilities and schools in Africa, whatever Westerners might think of them, and because religion is very important for most Africans.

Taken together, Green believes that the transformation of his maverick and unorthodox ideas into official US policy has been nothing short of groundbreaking. Indeed, it has been suggested by some in the HIV/AIDS community that Green’s two Congressional testimonies in 2003 and his influential book (sections were circulating in 2002) were key ingredients in the passage of the PEPFAR legislation in 2003. Why? Because a treatment program (the first AIDS-related idea that caught Bush’s interest) could not stand without resting on a foundation of prevention, and the Uganda prevention model seemed likely to be supported by a majority in a heavily Republican Congress.

June was indeed a good month for Ted Green. Perhaps more importantly, June was a good month for the application of anthropology to HIV/AIDS prevention thinking and to US policy.