Moralizing Pandemic: How Was HIV/AIDS Prioritized in Foreign Aid in the United States?

A dramatic foreign aid policy development in the US, the proclamation of the President’s Emergency Plan for AIDS Relief (PEPFAR), has been ascribed to the perception of a security threat. The securitizing scheme, however, has been debunked as a factoid not supported by empirical evidence. Despite the flaws of securitization as a causal theory, alternative explanations remain unexplored. This research seeks to address an alternative explanation, “moralization.” The article begins with a brief history of changes in the US response to the global AIDS crisis since the 1980s, followed by a description of securitization theory as an alleged explanation for the aid increase in the early 2000s. Next, this research problematizes the AIDS-security nexus and proceeds to show how a humanitarian approach to the epidemic invoked a moral obligation to respond urgently to the catastrophic epidemic. The moralizing rationalization entails the explication of perception changes among significant individuals within and outside of policy circles from the theoretical framework of agenda setting, namely the garbage can model. The research closes with the theoretical and empirical implications for the international relations discipline and foreign policy analysis, as well as for the current health crisis caused by COVID-19.
Keywords : HIV/AIDS, President’s Emergency Plan for AIDS Relief (PEPFAR), foreign aid policymaking, securitization, moralization

It is remarkable to see the concerted international efforts that have been orchestrated in response to one of the deadliest sexually transmitted diseases (STDs) in human history, Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS). The United States (US), which has been by far the biggest donor of international development aid in general, has likewise made a deep commitment to the global fight against this health crisis. The US’s global AIDS funding stands out particularly in comparison with its actions on other health issues like malaria or tuberculosis (TB), and even on other major development agenda such as food aid. As seen in Figure 1, the aid for AIDS has never stopped increasing (either incrementally or dramatically), unlike other areas of aid, which have either fluctuated or stagnated in their patterns and levels of commitment. What is more interesting is the fact that the aid has skyrocketed since the early 2000s culminating with the President’s Emergency Plan for AIDS Relief (PEPFAR), which is an unprecedented national foreign aid policy initiative that has allocated $15 billion exclusively to the fight against HIV/AIDS in the ten hardest hit countries over five years. How was such a dramatic upsurge feasible to tackle the specific medical issue? In other words, what underlying logic can rationalize the aid policy prioritization for AIDS?

The research contends that the dramatic funding increase was mainly caused by the framing (or perception) of the epidemic as a humanitarian crisis that required an immediate policy response. An ample literature, both from a policy point of view and a scholarly perspective, highlights how the epidemic was defined or perceived in order to delve into a driving force that galvanized the dramatic aid increase. One of the dominant frameworks is securitization ; this notion claims that the epidemic was regarded as a threat to national and international security (Garrett 1994Gellman 2000Brundtland 2003Prins 2004Singer 2002Feldbaum et al. 2006Fourie and Schonteich 2001Peterson 2002; Ban 200 2005; Ostergard 2002). However, this research challenges the preconceived causal mechanism but instead addresses an alternative underlying dynamic of the aid policy change, which is moralization .

In accounting for the moralizing process, it is important to consider how the idea or perception of AIDS has been recalibrated for policy agenda among significant political figures in policy circles. Methodologically, perception is hard to be empirically measured by hard evidences and it is even harder to show how (or whether) the perception influenced policymaking for real. It is also challenging to unveil whose perception matters than others’ in policy development. Conducting in-dept interviews would be the most apposite approach yet it is practically out of the question to contact then policymakers who engaged in the aid policy process twenty years ago. In lieu of interviewing, I adopt alternative strategy of process tracing within the framework of the garbage can model or policy stream approach.1 The approach, also known as Kingdon’s model, captures when and how certain issue, among others, is likely to gain the status of policy agenda by a group of policy entrepreneurs who develop and bring specific ideas into policymaking venues through a policy window being open at the moment of focusing events. This model is used as an analytical template of this research in tracing the process of new aid policy orientation for AIDS in the early 2000s, with focus on the perception of policy entrepreneurs like Bono, Franklin Graham, Jeffrey Sachs and Kofi Annan as well as Jesse Helms, Collin Powell and George W. Bush, who are thought influential to the policymaking for the US global AIDS funding. The emphasis on those allegedly significant political or policy individuals might not be enough to connect dots in the whole policy process but the historical narrative would help us to grasp a causal picture that depicts the aid policy mechanism for AIDS (Jacobson 2020, 151-152).

The contribution of this research can be addressed twofold; first, the moral discourse on AIDS is intriguing from the theoretical perspectives of international relations (IR), whose main interests are to examine what shapes actors’ interests or preferences, i.e., behavioral motivations. Foreign aid, a seemingly benevolent behavior, is particularly puzzling given that existing major IR theories claim that countries are egotistical and self-interested, mainly pursuing their own geopolitical or economic interests. A moral configuration tends to be ruled out as a relevant reference point for understanding the interaction of states embedded in an anarchic international structure. Therefore, discussion of what is right or appropriate has been treated as just an idealistic aspiration, rather than as a pertinent frame for scientific research in the IR discipline. However, the research seeks to expound how the ideational factors of humanitarianism or moral luster played a pivotal part in determining certain behavioral patterns in foreign policy. In this regard, the main contribution of the research is to put under scrutiny both micro-dynamics, such as individuals’ perception changes and their engagement in policymaking, and macro-level IR theories, in unveiling the moralization process whereby humanitarian ideas or a sense of moral obligation triggered states’ behavioral change.

Secondly, the research has timely implications against the back of the current health crisis of COVID-19 wherein the US failed to mobilize international cooperation for collective response to the pandemic. The inaction would be quite puzzling given the leading role that had been played by the US in global fight against AIDS. Lessons extracted from this research with regard to how perception matters would provide critical implications to unravel this puzzle. COVID-19 has been mainly viewed as domestic public health crisis as opposed to AIDS being framed as a humanitarian crisis that invoked moral obligations of countries with resources and capacities including the US. Based upon this research, the varying perceptions of the two epidemics are thought to have resulted in the concomitant policy responses of divergence.

The article begins with a brief history of changing US response to global AIDS, from the inaction of the 1980s to the dramatic aid increase in the early 2000s. Securitization theory is subsequently introduced as an alleged causal mechanism for the aid upsurge. Next, the crux of this research is the problematization of the AIDS-security nexus and the discussion of how the epidemic was deemed a humanitarian and moral imperative that required an urgent response. The moralizing rationalization entails the perception changes of significant individuals within and outside of policy circles from the analytical framework of garbage can model. The research closes with the theoretical and empirical implications for IR discipline and foreign policy analysis, as well as for the current health crisis caused by COVID-19.

During the two decades following the first official report of the collective symptoms of immune deficiency in 1981, the disease was primarily understood as an issue of domestic public health (Elbe 2006, 121). Such conceptualization did not galvanize major policy responses by the US government, either domestically or internationally. This section chronicles a historical trajectory of government responses (or lack thereof) to the pandemic from the 1980s to the early 2000s.

Government Inaction and Domestically Focused Response in the 1980s

From 1981, when the first AIDS cases were reported among male gay communities in San Francisco and New York, the US government response could be characterized as inaction2 or domestically focused response throughout the 1980s. The Reagan administration was reluctant to establish any policies to address AIDS (Behrman 2004Brier 2009Stockdill 2003). The US accounted for the largest portion of the number of global infections of the HIV that causes AIDS until the beginning of the 1990s, when the African continent turned out in fact the hardest hit by the pandemic. Despite the sizable HIV-infected population within the borders, the US was oblivious and unwilling to fight against the newly emerged medical quandary, even domestically.

The government inaction was attributed to the sexual and ethical connotations associated with the mode of transmission of the virus and the Reagan administration’s conservative nature and affinity to so-called born-again evangelical Christians. HIV/AIDS was not just a medical phenomenon but an issue with moral implications relating to family and sexuality, particularly in the view of the evangelical Christians, since the virus was known to transmit mostly through sexual contacts among gay males and extramarital sexual relations.3 The Christians were extremely sensitive about sexual or family-related issues so that HIV infection or AIDS outbreak was regarded as a punishment from God when they learned about the alleged correlation between the infection and such behaviors as homosexuality4 or promiscuity, both of which were seen sinful or deviant from the biblical perspectives. They also ascribed the infection to a personal choice to transgress against God’s will so that the responsibilities to protect and care for those suffering from the disease were seen as lying with the individuals themselves, rather than the government.

The view was critical to political conservatives, who were reliant on the Christian community for their political base. The homophobic trope of the Church group particularly infiltrated the conservative lawmakers. For example, prominent political veteran Jesse Helms, Republican Senator from North Carolina, strongly opposed any kinds of AIDS-related government programs for education or research due to his rock-solid Christian faith and efforts to advocate for religious values in policymaking. He considered HIV-infected people as engaging in aberrant sexual behaviors so that they deserved castigation and slow deaths accompanied by horrendous suffering (Altman 1986, 21Epstein 1996, 45-53). Furthermore, Helms had no political incentive to actively tackle the issue since his supporting constituencies mostly from the Christian community were not favorably disposed to government actions due to the ethical and religious implications attached to the disease (Kistenberg 2003, 13-18Smith and Siplon 2006, 13). As a result, the sexually transmitted disease was not determined to be an urgent issue that deserved an immediate governmental policy response.

The inaction seemingly came to an end in the mid-to-late 1980s, but only in the domestic realm. The epidemic came to be perceived as an issue of higher priority for US national interests in the blueprint for the fiscal year 1987 (Reagan 1986a). President Reagan even declared that AIDS “remains the highest public health priority of the Department of Health and Human Services” in the State of the Union Address on February 4, 1986 (Reagan 1986b).5 This was a noticeable change for a policy response to HIV/AIDS, scaling up the funds for vaccine development through the Center for Disease Control and Prevention (CDC) and the Department of Health and Human Services (HHS). The response, however, was concentrated exclusively on the domestic realm, without regard to the global dimension of the epidemic. This domestically centered response was attributable to the relatively large number of AIDS cases within the US.6 The already high and still increasing number of patients and deaths in the US alarmed not only the public, but also policymakers to whom “the domestic epidemic became a political firestorm” (Behrman 2004, 25). Behrman (2004, 25-26) spells out the phenomenon of domestically focused response: “[t]he battle lines seemed to be firmly entrenched within US territory […] There was no groundswell, no impetus, from American society at large to address the global dimension of the catastrophe percolating.”

US Disengagement from International Affairs in the 1990s

The global level inaction to AIDS lingered through the end of the 1990s due to the new international environment in the aftermath of the Cold War. The decades-long ideological, economic and political confrontation between the US and the Soviet since the end of the World War II terminated with the sudden collapse of the latter in 1991. Against the backdrop of the euphoria and bliss of the victory over communism, the US encountered the critical juncture with two diverging prospects of the post-Cold War international order: one outlook predicted a bright picture of a peaceful and prosperous international landscape by the leadership roles played by the US in upholding liberal values and rules as fundamental principles; the other view foresaw the opposite, envisaging that the US would get disentangled from happenings outside of the hemisphere in the absence of major nemeses or immediate threats to vie against, with sole focus on the areas of direct economic and strategic interests without consideration of global common causes.

The US in practice took the latter posture of insularity in foreign affairs particularly to the regions of little interest. Post–Cold War American society was fraught with self-assured hubris instilled by the triumph over the Soviets and the accompanying apogee it reached in the global hierarchy. The feeling of complacency entailed the lethargic attitude in the wake of the daunting enterprise of the Cold War and the concomitant apathetic sentiment toward issues seen as outside its interests (Lindsay 2000). The psychological perturbation stemming from the looming possibility of great wars during the Cold War was replaced by a cataclysm of indifference and apathy toward international affairs in the absence of palpable threats (Kissinger 2001, 18). The post–Cold War era of the 1990s was both too secure and affluent for the American people to be vigilant to engage in the morass of international affairs (De Zengotita 2002, 36).

The tendency toward detachment was particularly condoned in relation to Africa, the hardest hit by the epidemic. The continent accounted for approximately 85 percent of AIDS-related deaths and more than 70 percent of the people living with HIV, in addition to 95 percent of AIDS orphans in the world. However, nothing could inspire this smug but tired leviathan to take on the responsibility to care for those dying of and suffering from the pandemic in Africa. Not only did Africa lose its geopolitical and economic significance after the Cold War the US also became numb to the African quandary because of so-called passive racism; people in the US were less likely to be disquieted by ongoing predicaments in Africa, including the AIDS crisis, viewing them unceasing and irresolvable (Behrman 2004, 65-67). American people also glossed over the humanitarian quagmire in black Africa because the black population in the US did not constitute a major domestic constituency that could push the government for foreign policy engagement on their home continent.

The two decades of inaction eventually gave way to active policy intervention by the US in the early 2000s, culminating in the proclamation of PEPFAR by the Bush Administration in 2003. How was the inchoate ‘inaction’ replaced by such active engagement? What follows is a theoretical and empirical discussion to untangle the puzzle of the foreign aid policy change.

A large body of literature in the areas of political science and IR claims that the extraordinary aid increase was feasible because the epidemic was framed as a security threat. The literature has attempted to build a theoretical framework that captures the causal links between the specific view of AIDS and foreign aid policy response. However, I argue that this approach is problematic in explicating the mechanism of the aid policymaking and that an alternative scheme must be considered. This section first introduces the securitization theory and then explores how AIDS was believed to be securitized within the framework. The AIDS-security nexus is put under scrutiny, showing its shortcomings.

What is Securitization Theory?

Securitization theory emphasizes the intersubjective process by which certain phenomena come to be regarded as threats.7 The “security” label is added to a certain agenda, pushing it beyond the “normal political realm” toward a status that triggers or allows for exceptional responses (Buzan et al. 1998, 26). According to Wæver (19951997), a defining feature of securitization is the self-referential nature of the ‘speech act.’8 A particular issue is positioned through verbal interaction whereby “an intersubjective understanding is constructed within a policy community to treat something as an existential threat to a valued referent object, and to enable a call for urgent and exceptional measures to deal with the threat” (Buzan and Wæver 2003, 491). Such a consensus is reached among those in charge of public policymaking to deal with the threat in order to survive. It is political leaders who bring the grammar of security into such speech acts using terminology and concepts that are accepted by their audience. The speech act thus serves “as a strategic or pragmatic practice whereby discourse is used to increase public awareness or adherence to an idea” (McInnes and Rushton 2013, 121). “Normal politics” is replaced with emergency measures once or if agreement is reached with regard to the threat perception of a specific agenda (McDonald 2008, 567). It is noteworthy that the very utterance of ‘security’ does not describe reality, but constructs reality as a core of the framework of securitization. In other words, threat perception is created “not necessarily because a real existential threat exists but because the issue is presented as a threat” (Buzan et al. 1998, 24). The ‘performative utterance’ plays a role in constructing not only an intersubjective understanding but also social practice. In this regard, perception of reality matters, rather than (or in addition to) reality per se.

In addition to the speech act, the securitization ‘process’ (and/or ‘condition’) is also worth mentioning. Actors, including both securitizing actors and their audiences, are integral to the process. Securitizing actors attempt to persuade audiences, who subsequently determine to agree upon or discard the securitizing move based on strategic or pragmatic intentions. In the argumentative and persuasive processes, securitizing actors need to provide empirical evidence demonstrating the validity of the securitizing claims (Balzacq 2010, 22). The success or failure of the securitizing process is predicated upon the “robustness” of the empirical evidence to which audiences are exposed. Any “doubts about the evidence that underpins the securitization process can negatively impact upon audience perceptions” (McInnes and Rushton 2013, 120). In sum, so-called “facilitating conditions” increase the feasibility of the securitizing process: a widely-accepted grammar or terminology of security; securitizing actors in a position of power and authority; and objects generally held to pose a threat or historically associated with threat in a given community (Buzan et al. 1998McDonald 2008, 517).

Securitizing HIV/AIDS

The securitization framework was believed to fit the alleged causal mechanism of foreign aid policy with regard to HIV/AIDS in the early 2000s. First, there were speech acts that linked HIV/AIDS and the threats posed by it; the disease was referred to as an “existential threat to [the] state, especially to their political stability” (McInness and Rushton 2013, 122). The language of “security” was communicated in defining the pandemic among significant individuals in position of power not only in United Nations (UN) bodies but also in US government. The concept was used to persuade audiences by enhancing awareness of the critical impacts of AIDS. Let me chronicle the securitizing process of HIV/AIDS with a focus on the actors as well as the speech acts.

The first securitizing move toward global AIDS was United Nations Security Council (UNSC) Resolution 1308. The US ambassador to the UN, Richard Holbrook, exhorted then UN Secretary-General Kofi Annan to hold a UNSC meeting after he was shocked to witness a large number of AIDS orphans on the street in Lusaka, Zambia while travelling in southern Africa (Stenberg 2002). A special session was convened to discuss AIDS, its impacts, and possible response on January 10, 2000, which was the first time in UNSC history that a specific health issue was exclusively discussed. The Council subsequently adopted Resolution 1308 on July 18, which proclaimed that HIV/AIDS “if unchecked, may pose a risk to stability and security” given its “growing impact on social stability and emergency situation” (UNSC 2000, 1-2). It was a watershed moment in securitizing AIDS; a variety of dimensions of possible impacts from the epidemic were calibrated using the language of security threats by the top leadership of the UN, including Secretary-General Annan and UNAIDS Executive Director Peter Piot. The UNSC can be considered a securitizing actor that constituted the framework and circulated it to persuade audiences, including the international community and particularly donor countries.

The argumentative and persuasive process subsequently unfolded in the UN system. A virtually equivalent security frame was disseminated in the UN General Assembly in the Special Session (GASS) on HIV/AIDS that took place on June 25–27, 20019. The GASS marked a milestone in the global battle against HIV/AIDS. The Declaration of Commitment on HIV/AIDS adopted in the session portrayed AIDS as a “state of emergency” that destructively affected social cohesion and political stability in sub-Saharan Africa.

Speech acts on the existential threat of AIDS was also seen in US policy circles.10 The incipient security frame for AIDS can be traced back to a report by the Central Intelligence Agency (CIA) in May 1987 (CIA 1987). The report addressed concerns about “the ways in which AIDS threatens the security and stability of [the] state: its disproportionate effect on elites; the economic consequences of lost productivity, reduced tourism and long-term demographic change” (McInnes and Rushton 2010, 226).

The nexus became conspicuous in Washington policy circles in the 1990s. In a US State Department memorandum, AIDS was described as a “time bomb” that was likely to result in economic, political and military complications in the Sub-Saharan African region. (Department of State 1992). The view reverberated in the Presidential Decision Directives on emerging infectious diseases in June 1996 (Presidential Decision Directives 1996) and the National Intelligence Council (NIC)’s estimate report on global infectious disease in 1999 (NIC 1999). The two significant policy reports shed light on the global dimension of the disease and its security impact, both of which were a modality of the speech act in securitization theory. Then Vice President Al Gore also took an official part in a speech act on AIDS in the UNSC meeting in January 2000; he showed his trepidation by saying that AIDS “is a security crisis” as it “weakens workforces and saps economic strength…, strikes at teacher and denies education to their students” and also “strikes at the military, and subverts the forces of order and peacekeeping” (Gore 2000).

Despite the securitizing move, I would like to problematize the security–oriented claim. The existence of a given discourse does not necessarily mean that specific actions were aroused from the ideas. In other words, the securitizing move did take place, but the framework was not a good fit to explain the causal mechanism of the aid policy practice. In the following section, I challenge the widely-accepted security notion prior to constructing an alternative causal claim.

Debunking the Securitization Discourse of AIDS

The security/AIDS nexus has been hotly debated in both academic and policy circles. Critics have cast doubt on the validity of the empirical evidence to support the theory and the plausibility of the idea that audiences were persuaded as posited in the theory.

One of the major problems of the securitization claim is that the existence of the threat has not been vindicated by empirical evidence. Empirical evidence is an integral part of the securitization process (McInnes and Rushton 2013, 120). However, the idea of AIDS as a security threat was accepted as “received wisdom” such that few attempts, if any, were made to verify the sources or empirical evidence for the idea. Alleged truths accepted without validation are known as “factoids,” ideas cited so often that their original provenance becomes obscure and their empirical basis is overlooked (De Waal 2011). Barnett and Prins (2006, 363) define factoids as “soft opinion that have hardened into fact” and “pieces of data that look credible at first glance, but […] are insecurely grounded in evidence” without a careful vetting process. Factoids likely keep the meticulous verification procedure at bay because convictions tend to stand on self-evident conjecture rather than solid empirical objectivity.

In the case of AIDS, a gloomy prognosis was made by scholars, policymakers, and pundits beginning in the late 1980s as to the conceivable impacts and collateral repercussions of the pandemic on state functionality, including political instability, dysfunctional governance, and socioeconomic disorder (Garrett 2005Barnett and Dutta 2007De Waal 2003Moodie 2002Altman 2003; Barnett and Whiteside 2000), and military effectiveness and readiness (Whiteside et al. 2006UNAIDS 1998Elbe 2002), as well as the operational capacities of UN peacekeeping missions (De Waal 2010Tripoldi and Patel 2002). The pessimistic assertions and ominous extrapolations came to be proved false, or at best were upheld to a limited degree. The predicted threats of AIDS were conceived in many places as “emergencies” or “threats” based on “claims” of empirical evidence, rather than actual credible evidences.

UNSC Resolution 1308, the most significant breakthrough in securitizing AIDS, was believed to place high priority on aid policy that could respond to the pandemic. In contrast to our preconceived notion, however, the prominent securitizing moves in the Resolution with respect to the growing concern about threats to military personnel and operational capability turned out to just be received wisdom unverified by empirical evidence. In addition, there was no clear sign that the pandemic undermined state capabilities (MeInnes and Rushton 2013, 234-237). Barnett (2006, 310) empirically confirms that “although the HIV epidemic is in its third decade, we are still not seeing the full and cumulative social and economic impacts.”

The security discourse is also found in another key document that addresses AIDS response, the Declaration of Commitment on HIV/AIDS by UNGA, which is seen as having echoed UNSC Resolution 1308 (UNGA 2001). However, this does not mean that securitization is the dominant policy platform or focal point that spurred the change in aid policy with regard to the global battle against the pandemic:

“The Declaration made little reference to international security at all. It did highlight the fact that conflict and disasters can contribute to the spread of HIV […], and called on states to take action to reduce rates amongst their uniformed services […] but did not make the claim that HIV can contribute to bringing about instability and conflict. Neither did it make reference to Resolution 1308” (Rushton 2010a, 500).

In the case of another UNGA document, the Millennium Development Goals (UNGA 2000), which includes the eradication of HIV/AIDS among eight major development challenges that the international community faced at the turn of the new millennium, the disease was not even explicitly considered a security threat, except for a brief comment that HIV was burgeoning as a crisis in the global dimension (Rushton 2010b, 8).

Rushton (2010a) also probes other UN documents and statements by the Economic and Social Council (ECOSOC) and UNAIDS that have been thought of as milestones in global AIDS response. His finding, however, is that the security frame was almost nonexistent in the policy discourse of international governance (Ibid ., 500-501). Rushton (Ibid. ) reveals how reluctant Council members were to place the health issue within the Council’s traditional ambit of international peace and security. Not only were Russia and China at odds with the securitizing drive by US ambassador Holbrook, but so were France and later, even Great Britain. Those members were relatively unpersuaded by the securitizing claim, but could not veto Resolution 1308 because it would be too costly for their reputations to do so in the face of such outrageous human atrocity while the US power was pushing for the Resolution to be passed (Ibid. , 498). The situation behind the scenes explains the lack of clear security discourse in the prominent declarations and statements on AIDS that followed Resolution 1308.

In short, the securitization frame was not a major vehicle to catalyze the dramatic policy change, given the lack of clear supporting evidence for the threats in practice and the scarcity of security discourse within global governance regarding AIDS due to the failure in persuading process.11 Then what was the causal dynamics at work? How did the pandemic obtain top priority in foreign aid policy? What logic, if not securitization, can rationalize the dramatic escalation in the US’s aid like PEPFAR? This study attempts to depict an alternate picture that captures the causal process of the aid policy change. The following section is a crux of this research that sheds light on the framing of the pandemic as a humanitarian and moral issue as a real causal mechanism of the aid increase.

Perception matters for policy change; it is the idea or view of AIDS rather than the pandemic per se that triggered policy responses. Then which perception actually did galvanize the dramatic funding increase? I posit, as an alternative claim to the security framework, that the aid policy change was determined by the perception of AIDS as a humanitarian crisis by which a moral obligation was accompanied to immediately commit to fighting it. The moralizing process of policy adoption for active response to AIDS is to be unpacked here under the theoretical framework of policy stream approach.

Advent of HIV/AIDS as a Policy Agenda in the 2000s

According to Kingdon (1984), specific ideas, among many others, are adopted as real policy agenda through a complicated political process wherein a group of policy entrepreneurs promote and deliver them into policymaking circle when policy alternatives are sought in the immediate aftermath of focusing events. Policy entrepreneurs are a community of people who share similar ideas, outlooks, and perspectives based on causal beliefs about certain problems and solutions in their policy proposals. The package of ideas (perceptions or perspectives) about issues (problems) as well as solutions is called policy agenda. Policy entrepreneurs are loaded with pre-prepared ideas (about problems and solutions), and persistently float around waiting at the gate of the policymaking machine until a “policy window” opens, through which the ideas are put forth to be adopted for action (as real policies). It should be noted that the nature of the policy process is not necessarily linear; ideas about solutions often precede the realization or awareness of a problem itself. Advocacy of ideas is promoted by the policy entrepreneurs who “wait for problems to come along to which they can attach their solution” (Ibid. , 93-94). The opportunity is so fleeting that it is more likely for policymakers to choose policy prescriptions among pre-prepared schemes that have already been resonating within policy community prior to crisis. Policymakers can’t afford to wait for burgeoning ideas subject to be scrupulously thought out from scratch after crisis happens.

The Kingdon’s approach is applied to scrutinize the dramatic aid increase for AIDS in the early 2000s. No government policy response could be exhorted in the first place when the sexually transmitted disease was framed among born-again evangelical Christians as God’s punishment for sexual transgressions. This initial framework was reconsidered and recalibrated by the advocation of a new perception that the epidemic was a humanitarian catastrophe from which even many innocent people were suffering and dying. This brand-new framework entailed a moral obligation, which drove the drastic policy shift for helping those in dire heath crisis (Cooper 2015, 55). It is quite ironic that the two totally idiosyncratic reactions to the disease, animosity and concomitant incrimination on the one hand and compassion with a moral onus to act on the other hand, originated in the same Christian Bible. The latter gradually prevailed through the efforts of policy entrepreneurs who attempted to change the preconceived notion that had been pervasive mainly among conservative political figures in foreign aid policy circle.

However, the humanitarian trope would not have been taken on as an agenda for real policy if a policy window did not open. It is in a sense fortunate, albeit totally devastating for the American people and for US national security, that the focusing event of the terrorist attacks on September 11, 2001 gave way to a new environment in which the idea of AIDS as a humanitarian crisis could successfully penetrate policymaking circles, leading to the dramatic increase in aid. What follows is: (1) how the perception of AIDS changed from a punitive consequence of sexual transgression to a humanitarian crisis accompanied by a moral obligation to respond; and (2) how the terrorist attacks opened the policy window for the ideas to enter the policy agenda, resulting in the dramatic increase in global AIDS funding.

How Perception Changed: Religion, Compassion, and Development

First, the policy entrepreneurs like Bono, Franklin Graham, Jeffrey Sachs and Kofi Annan sought to redefine AIDS crisis as a humanitarian issue. Having witnessed the devastating distress inflicted on the large number of HIV-infected people and those with AIDS, particularly in sub-Saharan Africa, they shared the perception of the pandemic as a health crisis that the international community had a moral obligation to grapple with on humanitarian grounds. They played a pivotal role in changing the perception of significant political figures in charge of US foreign aid policy.

The first two individuals were strongly motivated by their Christian beliefs. Franklin Graham, the son of the renowned evangelist Reverend Billy Graham, who was leading a faith-based organization called Samaritan’s Purse, did not proselytize the then widespread view of AIDS as a punishment from God. He regarded it as an agenda that needed to be approached with Christ’s love and sympathy when the organization’s missionaries in Africa witnessed death, suffering and orphaning caused by AIDS and called the egregious scenes a holocaust (Dyer 2014, 1017). Graham committed the organization to mobilize US engagement in the battle against AIDS on religious as well as humanitarian grounds (Behrman 2004, 270).

Their religious motivation particularly appealed to politicians of Christian faith like Jesse Helms to change his view on AIDS. He had originally vilified the HIV-infected people and detested any governmental policy response to the deserving consequences of individual choices of abhorrent and unbiblical behaviors including homosexuality and promiscuity. The attitude of this political juggernaut dramatically changed ironically due to his religious belief; Helms confessed, “I’m so ashamed I’ve done so little … I will do better than I have done in the past and I will work together with you” in his speech at the Prescription for Hope conference hosted by Franklin Graham in February 20, 2002. Gill (2006, 30) described the remark as “a decidedly unexpected mea culpa from a perennial adversary of U.S. funding for global AIDS.” Helms’ altered view based upon the religious creed became more evident when he called for an additional $500 million to halt mother-to-child transmission of HIV in his Washington Post op-ed on March 24, 2002; he wrote, “[O]ur conscience is answerable to God….I know, like the Samaritan traveling from Jerusalem to Jericho, we cannot turn away when we see our fellow man in need” (Helms 2002).

Helms’ perception change can also be attributed to another figure with a religious background, Paul Hewson, better known as Bono, the leader of the Irish rock group U2. This successful musician is famous as a serious Christian committed to the social teachings of the Bible, albeit one who is popular due to his musical prowess as well. Bono coaxed Helms using biblical lessons. “[Bono’s] advocacy… was an outgrowth of a strong desire to serve the suffering” based on his dedication to Biblical teachings (Behrman 2004, 276-277). Since the late 1990s, he has been active in promoting Christian values in US response to global issues, such as the debt relief campaign Jubilee 2000.12 The connection between his lofty religious values and a commitment to international development aid was guided by Harvard economics professor Jeffrey Sachs13. Bono had the opportunity to be tutored by this scholar, who is not only influential in academia but also in policy circles relating to macroeconomics, aid for Africa, trade reform and health issues such as AIDS. For Sachs, the pandemic was a “silent holocaust” from a humanitarian perspective, and also an irreversible setback to sustainable development in Africa, from which he believed the international community should not turn away (Kaiser Health News 2002).

Equipped with both ideals and practical knowledge, Bono lobbied influential political figures in US policy circles to galvanize government response to the urgent health catastrophe in Africa. His first target was Senator Jesse Helms, one of the most formidable adversaries of US intervention in the global AIDS crisis, whose devout Christian identity stymied the government from funding the fight against AIDS. Helms met with Bono in the summer of 2001 for two hours in the Senator’s office. He confessed later that Bono had shared with him 2002 Bible verses which inculcate us to help our fellow men whose lives are at stake (Behrman 2004, 273). The small Bible session with Bono awakened Helms, transforming his obstinacy into generosity toward those suffering from the disease, in the form of a legislative initiative. His stubborn opposition to government policy intervention changed, ironically due to the same religious convictions that had initially led him to oppose such interventions. In 2002, Helms and Tennessee Senator Bill Frist14 co-sponsored a legislative proposal, an Emergency Supplemental bill that committed $500 million to fight mother-to-child transmission. The proposal became known as Helms’ legacy amendment for the US to be recognized as a compassionate nation (Messac and Prabhu 2013, 127).

Bono expanded the boundaries of his AIDS advocacy toward influential individuals in the US foreign policy cockpit such as Secretary of State Colin Powell. Powell had gravitas in the area of foreign affairs when he was appointed Secretary of State in the administration of George W. Bush following his thirty-five-year military career and his role in foreign relations during the presidencies of both Reagan and George H.W. Bush. Powell had a strong belief that the US was a great power that should exert leadership in cooperation with allies multilaterally. This internationalist orientation held the suffering of Africa in special regard such that AIDS was not lost among other foreign policy challenges under the incipient Bush administration at the dawn of the new millennium. Powell laid bare his deep concern about the humanitarian complications roused by AIDS in a television interview on ABC on February 4, 2001 that the epidemic was not just a national security and economic issue, but “a devastating problem, especially for Africa” that “requires our attention” given its tragic impact (Behrman 2004, 264). Knowing that the new Secretary of State would be an ally in this battle, Bono helped consolidate both Powell’s perceptions of the pandemic as a humanitarian catastrophe and the US obligation to fight against the most insidious enemy of our time (Berke 2001). He lobbied Powell to organize an aid project for Africa. The project was launched after Powell’s visit to the continent in May 2001. The horrendous scenes Powell encountered during the trip kept haunting him to reconfirm his policy commitment to the region (Behrman 2004, 272).

It is also worth discussing the influence of Jeffrey Sachs and Kofi Annan, who fostered the perceptions about AIDS with specific regard to sustainable development in Africa. Annan, as UN Secretary-General, was particularly interested in cultivating his own sui generis vision of how to maintain and improve the continent’s economy without relying solely on foreign aid for its survival. He described AIDS as the biggest development challenge and the single greatest cause of death in Africa in a talk at the African Summit in Abuja, Nigeria on April 26, 2001 (Annan 2001). Jeffrey Sachs, the Harvard economics professor and international development guru, reverberated Annan’s points, proclaiming that the health crisis that had caused an overarching development conundrum in Africa consigning the continent to “a poverty trap” from which they were unable to get out by themselves due to a lack of political and economic resources (Attaran and Sachs 2001).

In short, religion, compassion, and development all factored into the shaping of the perceptions of HIV/AIDS as a tragic event that morally obligated the US to make an immediate policy response on humanitarian grounds. The remarkably high death tolls and the prevalence of HIV and AIDS in many sub-Saharan African countries who could not afford to fight the pandemic on their own called for the moral duty of international community to save the lives at stake and to help improve their socioeconomic conditions for sustainable development. Inaction in the face of such humanitarian imperative would be considered immoral. However, the idea did not automatically entail the establishment of specific policies until a policy window was unexpectedly opened by the calamities on September 11, 2001.

Policy Window Opened: Unexpected Consequences of the 9/11 Terrorist Attacks

A perception change is crucial for policy development, yet that does not necessarily mean that any perception or idea can automatically move up to the status of policy agenda. In other words, timing may allow one idea among many to take precedence over others on policymakers’ radar. Ideas developed by policy communities generally lie dormant until a crisis occurs, which tends to break policy inertia and creates an opportunity for the community to promote them. Kingdon (1984, 174-177) calls this moment a “window of opportunity.” The window opens along with focusing events that “play a major role in agenda setting by creating opportunities for advocates from policy communities to pursue well-established beliefs and to promote well-developed policy alternatives” (Mazarr 2007, 13).

When it came to the window of opportunity for global AIDS response, Behrman (2004) pinpoints the terrorist attacks on September 11, 2001. The horrific provocations by Islamic extremists who hijacked American commercial aircrafts traumatized people across the world. The shambolic events engendered unfamiliar emotions of panic and tantrum among Americans as well as a sense of uncertainty particularly over the prospect of a post-9/11 world order. Despite this general feeling of perplexity, however, it became obvious that the US, which had been oblivious to international affairs for a decade, could no longer afford the luxury of peace and aloofness it had enjoyed since the end of the Cold War. The critical juncture awakened the US of its destiny as the only superpower of the time and prodded it to change the way of conducting foreign policies.

When this policy window opened, a rush of suggestions was made available to policymakers who were craving a new foreign policy orientation following the historic incidents. Some foreign policy pundits conjectured hastily that the US should exclusively focus on impending security issues like the war on terrorism while dropping seemingly less urgent issues like global public health from the agenda. However, such security-oriented foreign policy direction was rejected. The security tribulation ironically inspired the US to reengage in international affairs in a more encompassing manner, including addressing the global AIDS crisis. Contrary to widespread speculation, “the attack summoned Americans to wake from the insularity and slumber of the 1990s to consider the world anew” (Ibid. , 269). The US realized that it had to use “soft power” to establish anti-terrorism measures in conjunction with its allies. Soft power would also be an effective way to prevent enemies such as Islamic extremists from rising up in the first place. The return of an internationalist identity enabled a humanitarian and moral framework for response to the AIDS crisis to emerge on the foreign policy agenda.

Bona Fide Commitment by George W. Bush: The President’s Emergency Plan for AIDS Relief (PEPFAR)

In the midst of the policy competition that followed the terrorist attacks, the moralizing view of AIDS was put forth to the White House as a policy agenda. The government was disquieted by security concerns after the attacks, and foreign policy options were canvassed to sanitize the image of the US as a part of the global war on terror. The US sought to be viewed as international police, with both the muscle to vanquish any nemesis that challenged international security and order and the moral authority to serve as a benign, and generous leader promoting values and principles for a more humane world. Foreign aid for AIDS fit with this latter quality, as it would save lives and provide care for Africans in desperate need. The agenda had already been circulating in Washington policy circles via the work of policy entrepreneurs like Bono, Franklin Graham, Jeffrey Sachs, Senator Jesse Helms, and Colin Powell, who introduced it to the policy center of gravity, President George W. Bush.

Bono’s meeting with the President was particularly momentous. During an hour-long conversation in the Oval Office, Bono quoted scriptures to instill a Biblical perspective from which to approach issues and problems in Africa, including AIDS. The epidemic was viewed as a critical humanitarian catastrophe commensurate with “genocide” that desperately awaited immediate succor (Behrman 2004, 275Dietrich 2007, 282). The President and his conservative supporters had mostly been loath to commit government funds to AIDS due to their religious convictions. Ironically, it was the Christian faith immersed in the perception of AIDS that catalyzed the remarkable policy response. “Bono was helping the White House put the “compassion” back in “compassionate conservativism” (Behrman 2004, 276).

In his State of the Union address on January 28, 2003, President Bush made a historic announcement regarding the US commitment to the fight against HIV/AIDS, introducing PEPFAR. He pledged $15 billion for AIDS prevention and treatment in ten targeted countries. The aid was earmarked to prevent seven million people from being infected with HIV and to provide treatment to two million who had been suffering from HIV-related disease (Bush 2003a). Many people, even in major policymaking circles in the White House and Capitol Hill, were astounded and exhilarated by the unprecedented level of commitment the US made to this higher cause.

The idea underlying the commitment was a humanitarian one. In the State of the Union address, Bush described the extraordinary aid as “a work of mercy” that should be extended beyond “the urgency, priority, or scale of traditional “national security” threats” (Ibid. ). Given the humanitarian and moral orientation, the State of the Union was the moment that “the world’s greatest power would embrace a worthy national mission that would unleash its better and nobler angels. It would take one giant step closer to realizing its potential as that shining city upon a hill, a beacon for mankind and what man might be” (Behrman 2004, 313). The motivation of the commitment was officially reconfirmed during Bush’s visit to Africa in July 2003, when he gave a speech in the AIDS Support Organization Center in Entebbe, Uganda: “You know, I believe God has called us into action. I believe we have a responsibility. My country has a great responsibility” (Bush 2003b, 862).

HIV/AIDS is one of the most egregious infectious diseases in human history, having claimed approximately 34.7 million lives. In addition, 37.6 million people were still living with HIV globally as of 2020. However, it is worth highlighting that huge improvements have been made in AIDS prevention and treatment. According to UNAIDS, since the number of new annul infections peaked at around 2.8 million in 1998, it has declined by 40% to 1.5 million new infections in 2020. When it comes to AIDS-related deaths, there has been a more than 61% decline from the peak of 1.8 million in 2004 to 690,000 in 2020. Another hopeful statistic is that 84% of people living with HIV know their HIV status as of 2020. Among the people knowing their infection, 87% or around 27.4 million people around the world have access to antiretroviral therapy, and 90% of those who received the treatment were virally suppressed (UNAIDS 2021).15 A big part of these achievements has been ascribed to the collaborative efforts of the international community, particularly the outstanding commitment of the US since 2003.

In accounting for the dramatic foreign aid policy development, this research employs a microscopic approach to the policymaking process and the underlying forces that enkindled it. The view is at odds with the general IR theories which regard state-actors and their interactions as the major unit of analysis. It is meaningful to focus on the big picture of the international landscape with an emphasis on states and their behaviors, yet attention must also be paid to what happens inside the box in order to unpack the underlying process and dynamics of foreign policymaking. Much remains to be seen and discussed to depict a full causal picture of foreign (aid) policymaking beyond IR theories by illuminating the way in which perceptions amongst significant political and policy figures are reshaped or transformed.

The research contends that perception matters in foreign aid policy response. Objective reality exists, but an image of the reality is projected through the lens of perception. Individual policy actors have varying views depending on their choice of one perspective over others. A particular perception chosen by those in power determines the distinct policy orientation which reflects how they interpret the reality. When it comes to the aid policy change for AIDS in this research, the preconceived notion of securitization is discredited, and instead the alternative conception of moralization is presented as a driving force for the policy change. This normative approach might not be a very popular causal framework in IR discipline which tends to focus more on materialistic configurations like security, military or economic interests. The main contribution of this research, therefore, is to show how perceptions (of what is right or what should be done for humanitarian purposes), in lieu of (what is best for) material interests, played out in cultivating the policy interventions for global AIDS crisis from a microscopic viewpoint of foreign policy analysis.

Lastly, it is worth mentioning the timely implication of the research to the current crisis of COVID-19. Following the initial lack of international cooperation more than one year from the outbreak at the end of 2019, international cooperation such as global vaccine roll-out has been launched by the US to a certain extent since 2021. The transition from inaction to the incremental (or dilatory) collaboration would be explained by the changing frame of the pandemic. The perception of COVID-19 primarily as domestic public health crisis during 2020 might bear some semblance to the case of AIDS in the 1980s. Such perception that fomented domestically centered response to AIDS thirty year ago analogously reoccurred in recent case of COVID-19. Subsequently, the catastrophic impacts of the pandemic to developing countries like India or countries in Africa bereft of the capacity to inoculate their own population drew the attention of aid-giving developed countries. The donors who brood over the protracted humanitarian effect of COVID-19 tend to instigate international cooperation based upon the redefining of the pandemic, which is akin to what happened to AIDS in the early 2000s.

The lessons learned from this research on moralizing AIDS will be an inestimable boon to further research questions. For example, a moot point would be under what condition (or/and by whom) certain pandemic is more or less likely perceived as humanitarian (or security) issues. This research also challenges us to speculate how to invigorate internationally concerted efforts to halt looming pandemics or prevent any global crises in the offing.

1 The origin of garbage can model can be traced back to the organizational model of public policy choice by Cohen et al. (1972).

2 The inaction was not limited to the federal government, but extended to the whole society. See Padgug (1989) and Shilts (1987) for the inaction of the medical profession, scientific research establishments, and the mass media as well as the federal government.

3 Collective fear and trauma were pervasive among the public due the alleged connection of the disease with homosexuality. See Stockdill (2003) regarding the stigmatization of the public and government inaction.

4 AIDS was mainly portrayed as a “gay disease” owing to the high proportion of gays among people with HIV or AIDS.

5 Reagan publicly used the word “AIDS” a total of five times while in office, and this was the first time that the president officially mentioned the disease, particularly in the context of national interests and as a major threat to public health.

6 The CDC reported 452 diagnosed cases of AIDS and 177 AIDS deaths as of July 8, 1982. The end of the decade saw almost 115,000 diagnosed cases and more than 70,000 deaths. By the year 1995, there had been roughly 500,000 cases and more than 300,000 deaths just in the US.

7 The process of constructing security perception was theorized by the Copenhagen school. See McSweeney (1996) and Stritzel (2007) for the Copenhagen school’s securitization theory.

8 Original works on the nature of speech acts can be found in Austin (1962; 1971).

9 The UNSC reconfirmed the existential threat once again following the UNGASS on HIV/AIDS in June 2001 (UNSC 2001, 1).

10 Warnings were given regarding the demographic impact of AIDS in 1987 by the Secretary of HHS, Dr. Otis R. Brown (AIDS May Dwarf the Plague 1987) and Harvard biology professor Stephen Jay Gould (Gould 1987). They did not use the word security threat, but they panicked people by extrapolating an exponential increase in AIDS victims both domestically and internationally.

11 A group of scholars (Barnett and Prins 2006Elbe 2006Davies 2008Shiffman 2008) find fault with the security/AIDS nexus for ethical reasons. They point out that the frame would exacerbate situations and generate detrimental consequences, including overpowered states and concomitant human rights violations, Western-centered health governance that marginalized the needs of local people or developing countries, and the displacement of crucial aid to address other health issues, etc.

12 For more on Bono’s celebrity, religious belief, and commitment to addressing development in Africa, see Tyrangiel (2002).

13 For the details on Sachs’ commitment to the global AIDS campaign, see Donnelly (2001a).

14 Senator Bill Frist also contributed to framing AIDS as a humanitarian catastrophe. A medical doctor himself, he frequently visited Africa and witnessed firsthand the tragic reality caused by the pandemic (Grann 2003). He proclaimed that the US had a moral obligation to fight the health crisis as a compassionate nation, which would be recorded in history and remembered by its descendants (Donnelly 2001b).

15 UNAIDS set intermediate goals toward the total eradication of AIDS, the so-called “90-90-90: Ambitious Treatment Target to Help End the AIDS Epidemic.” The plan set a target by 2020 that “90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression” (UNAIDS 2014).

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SAKHRI Mohamed
SAKHRI Mohamed

I hold a bachelor's degree in political science and international relations as well as a Master's degree in international security studies, alongside a passion for web development. During my studies, I gained a strong understanding of key political concepts, theories in international relations, security and strategic studies, as well as the tools and research methods used in these fields.

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