Only last week, David Brooks was praising President Obama, and actually cited the fact that he allowed Dr. Mark Dybul to stay as an example of Obama’s bilateral approach to government:

Dybul is one of those heroes one meets too rarely in government. He worked as an AIDS doctor in San Francisco in the 1980s and when the worst effects of the plague migrated to Africa, he did too. Then George W. Bush hired him to run the President’s Emergency Plan for AIDS Relief program before promoting him to Global AIDS Coordinator…I traveled through Namibia, South Africa and Mozambique with him once and was incredibly impressed.

Well, that “bipartisan” appointment lasted less than a week. Too bad that political correctness is more important than keeping a “hero” in a bureaucratic position.

Because it is hard to think of a better word than “Hero” to describe Dr. Dybul, the man who headed the HIV prevention/treatment program that probably has saved two million lives in Africa.

So why has President Obama, in his first week in office, done this?

From the Washington Post:

But someone at State or the White House determined that sacrificing Dybul would appease a few vocal, liberal interest groups.

One high-ranking Obama official admitted that the decision was “political.” Yet the AIDS coordinator is not a typical political job… It involves directing a massive emergency operation to provide lifesaving drugs, through complex logistics, to some of the most distant places on Earth.

And now that operation may be months without effective leadership — undermining morale, complicating interagency cooperation, delaying new prevention initiatives and postponing budget decisions.

Actually, the decision is part of a larger agenda.

So far, President Obama has removed regulations guaranteeing the civil rights of health care workers who refuse to cooperate with abortion (and euthanasia); he has authorized American taxpayer money via USAID to fund abortions overseas, including  replacing funding to groups that indirectly fund forced abortions in China (in a slight of hand, their money funds non coerced family planning, thereby freeing up money in the tight budget to fund forced abortions).

More importantly, your tax money will now be used to fund groups that pressure governments in Catholic and Islamic countries to change their abortion laws.

Right now, in the Philippines, there are politicians trying to promote (read coerce) birth control in government clinics, teach “safe sex” in high schools, and limit childbearing to two children, similar to China’s policies.

Is the low HIV rate in the Philippines due to their reactionary policies in promoting family friendly agendas? Who knows? But several countries in Africa that have started to promote responsible parenthood, delaying the onset of having sex, and stressing relationships with protection rather than safe sex (which usually means “safe promiscuous sex”) have also seen a drop in new HIV cases.

When one does development work, including public health, one has to work with the local cultures. You are not trying to quickly make them into Europeans or Americans. First you find what the locals feel is the problem, and then you figure out how to help.

This might mean pushing a moral agenda, if you are a church or a gay rights organization. But you have to build this on top of the local culture.

For example, if you are working to decrease maternal mortality, it might mean training  local midwives to encourage breastfeeding,  promoting natural family planning via church groups, and encouraging the local imman to preach against infundibulation as a pre Muslim practice that Mohammed discouraged.

Dybul has stressed the importance of working with local groups at the grass roots level as the key to solving the HIV crisis. He notes that the same techniques that work among the gays in San Francisco might not work in other cultures, and is correctly pragmatic about different methods in different populations.

So although the PEPFAR program has given out 2.2 million condoms, it has also worked with church and government programs that promote abstinence/fidelity and that discourage promiscuity among the general population.

How gauche.

From the WashingtonBlade via Southern Voice:

 Among the groups that called on Obama to replace Dybul as AIDS coordinator were the International Women’s Health Coalition and the Sexuality Information & Education Council of the United States, which advocates, among other things, for gay-sensitive sex education program

This is the clue to his “resignation”. SIECUS was founded to promote sex education and to promote a broader, progressive cultural change.

Then there is this criticism from someone associated with Johns Hopkins University in Baltimore:

“I think the evidence is overwhelming that abstinence programmes aren’t effective, that they don’t reflect the reality of the world we live in,” said Bennish, adding that his organisation struggled with a PEPFAR ban on the use of its funding to distribute condoms at schools, a rule that clashes with national policy in South Africa, which states that any child over the age of 12 can consent to reproductive health services. (italics mine).

The “naive” person in this is not Dybul.

The reason that any child over the age of 12 can “consent” to “reproductive health services” in South Africa is because too many young girls are sexually exploited, and need treatment for STD’s, and pregnancy. Some of the girls trade sex for food or gifts; others are  sexually exploited by relatives or others in their homes, and still others are raped because of the folk belief that sex with a virgin can “cure” HIV.

From an AVANT report:

Although HIV prevention campaigns usually encourage people to use condoms and have fewer sexual partners, women and girls in South Africa are often unable to negotiate safer sex …. They are also particularly vulnerable to sexual abuse and rape, and are economically and socially subordinate to men. Police reports suggest that in 2004-2005 there were at least 55,114 cases of rape in South Africa, although the actual figure is undoubtedly higher than this since the majority of cases go unreported.

Until you “reeducate” men, you won’t do much to stop the problem.  Stressing the use of a condom during coerced sex is not the answer. Shame will not stop the problem completely, but a society that educates young men to respect and protect women, and one that that shames powerful men who rape will go a long way to slowing the problem.

And actually, funding government and church programs that promote the idea of abstinence and against promiscuity does indeed work if your program is aimed at the broader population.

It allows the HIV organizations to work with churches and mosques (who are an influential non government organization in Africa). And funding abstinence/fidelity reinforces the traditional values that stress protection of the woman.

The result is fewer “one night stands”, delaying the onset of sex in teenagers, and (more importantly) for the educated African, the return of the second wife: a mistress (or polygamy) instead of promiscuity.

As for “gay rights”: it is a non issue for HIV in Africa. In less sophisticated areas, many Africans see “gay rights” as merely affirming the right of powerful men (who often are married and bisexual) to exploit boys, not as a consensual relationship. Discouraging promiscuity/sexual exploitation is the first step to actually affirming the rights of mutual gay relationships to flourish.

Like anywhere else, a lot of people will continue to do what they want anyway, but reinforcing traditional morality does give a negative reinforcement to behavior and slowly changes cultural ideas (similar to anti smoking campaigns in the US).

This allows the government to stigmatize behavior that is undesirable (promiscuity, drug use), while letting small independent programs to work with the marginalized addicts and sex workers.

In effect, this is what the Bush program was doing: Concentrating on certain areas, but not trying to be all things to all people.

There have been other criticisms of the Bush HIV program.

One:that it ignores other more common diseases among the poor–such as TB, Malaria, and dysentery.

Yet one has to start somewhere. If  a program has too broad an agenda, nothing gets done.

Two: that the programs pay larger salaries so physicians no longer work in government hospitals.

Yet doctors too have to live, and they often support large extended families. Without the good salary at the HIV clinics, many would probably emigrate elsewhere.

Three: That we should spend the money in nation building instead:

John Prendergast and John Norris of Enough, a US-based project to end genocide and crimes against humanity, took a different view in a recent strategy paper: “While responding to the HIV/AIDS pandemic is a crucial priority, if US development assistance becomes skewed too far in this direction, it will become very difficult to make long-term investments in state-building, the rule of law, basic education, and economic growth.”

Ah, but the dirty little secret is that HIV has decimated the educated population in many countries. How can one build education and the economy if the businessmen and teachers are dead or dying?

And finally, the complaint that the program requires too much paper work. I sympathize. But the reason for the paperwork is to prevent the money from being stolen or diverted to other uses.

In summary, the callus firing of Dr. Mark Dybul is an example of politics at it’s worse, and his “sin” was being able to promote HIV treatment and prevention programs that were culturally sensitive.

And his firing (not “departure”) is an example of partisan politics at it’s worst.


Nancy Reyes is a retired physician living in the rural Philippines. She has worked in Africa and later in cross cultural medicine in the US for much of her career. She writes at HeyDoc Xanga Blog.

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