Bates: Prevention Requires More Accountability

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Newsmaker Interview

Christopher Bates is a unique breed in today’s political milieu. He’s an openly gay Black man who is at the center of the Bush administration’s AIDS policy shop. As acting director of the Office of HIV/AIDS Policy in the Department of Health and Human Services, Bates often speaks for an administration that many feel is disengaged from and often openly hostile to HIV prevention. Bates rejects that characterization, arguing that the administration has broadened the way prevention is addressed, particularly when it comes to abstinence and accountability measures.

But Bates also speaks with remarkable candor on topics that aren’t usually associated with his boss in the White House: The need for open and honest dialogue about sex, the wellbeing of Black America’s next generation, and both the power and the challenge of being Black and gay in today’s culture. editor Kai Wright caught up with Bates during the National HIV Prevention Conference in Atlanta. Has prevention worked? Has what we’ve been trying worked?

Bates: I’m a big believer that prevention does work. I think where we are challenged in prevention is the level of intensity that is often times required to do this work. Meaning, a lot more individual activity has got to take place, rather than trying to do purely posters and public media blitzes.

You’re talking about one-on-one…

I’m talking about one-on-one or small group interventions. They are very, very effective, in those communities where they do that kind of work. In particular with young people, it’s effective. But we run up against things such as parental consent, support from school boards, that kind of thing. So it’s very hard to get to young people in the absence of that kind of support. Some kids don’t get the level of intervention necessary to modify their behavior. The president has put forth an initiative called ABC [short for “Abstinence, Be Faithful, use Condoms,” a prevention perspective that stresses abstinence until monogamous marriage, but still teaches about condom use as well] which I am a staunch believer in. I think young people, especially between 9- and about 16- or 17-years old, shouldn’t be having sex–even though, we know they do. But we have to give options to kids, and we’ve only been talking about abstinence in a very aggressive way in the last couple of years.

But what about the distinction between—there’s ABC and there’s abstinence-only. Now one of the criticisms is that all of the money in fact is going to abstinence-only.

All the money is not going to abstinence-only. Abstinence-only takes up some of the funding, but that’s generally not been a part of our prevention strategy. On the CDC side, that’s been part of a carve-out for a program for the Administration for Children and Families—there’s a component of the CDC that focuses on that. But all that’s youth-focused, and that youth focus is really between about 9-years-old and 16 or 17. It doesn’t include kids who are 17, 18, 19 or 20—the years that are most impacted by HIV right now, the older group. We’re not solely selling them on abstinence.

And beyond youth then, the other question is how do you do prevention with adults. Certainly, earlier in the Administration at least, there’s been a feeling that you have placed limits on it—that you don’t want words like “sex worker” in grant proposals and so on. Is that a justified feeling that people have?

Remember, Congress passed legislation back in the 90s that said no federal dollars could be used to promote sexual behavior, whether that sexual behavior was targeting gays and lesbians or heterosexual people. So any campaigns that are funded by federal dollars cannot even have the look of promoting sexual behavior, between consenting adults or others. That’s just the fact. It does not preclude communities form taking private dollars and other dollars to do sexually-explicit campaigns if they so chose.

But do you think that’s a good or a bad thing? I know the law exists but…

I don’t make a judgment about that. I’m a bureaucrat and I follow the leadership mandate.

Well, beyond the law, do you believe that sort of explicit sexual talk needs to occur?

I think that some is definitely important to our conversation, because I look at it this way: We have some segments in our community that are what I call sexually sophisticated. [Laughs.] Meaning their sexual explorations are not at a novice or virginal level, that they have had multiple sexual partners over many years of experience. And in that context, I think the approach to them needs to be far different than in a context of somebody who is recent to or considering sex. I think people who are considering

Well, beyond the law, do you believe that sort of explicit sexual talk needs to occur?

I think that some is definitely important to our conversation, because I look at it this way: We have some segments in our community that are what I call sexually sophisticated. [Laughs.] Meaning their sexual explorations are not at a novice or virginal level, that they have had multiple sexual partners over many years of experience. And in that context, I think the approach to them needs to be far different than in a context of somebody who is recent to or considering sex. I think people who are considering sexual behavior need to have more options than a condom. They should have options of finding a monogamous partner or choosing not to have sex until such time that they feel they’re prepared to emotionally and psychologically engage. And that could be a full adult! [Laughs.] This is not just for youth, because maturity is not something you get overnight.

It’s a point we often overlook! But all of these things imply—this sort of intensive prevention you describe doesn’t come cheap. Are we spending enough money on prevention?

I think we’re spending a lot of money on prevention. Enough? I’m not sure what enough is. But I can tell you that all communities are currently being challenged in many ways around their prevention interventions. One, they have to be science based–primarily based on a compendium of variables that we’ve identified, that have gone through some scientific rigor–so that we can talk about outcomes of interventions. Just because they make people feel good—they’ve gone to a session—doesn’t mean people walk away with skills and capabilities, and also have been psychologically convinced that they’re equipped to modify their behavior such that they don’t put themselves at risk. We need to know what any intervention’s ability is to impact behavior and we need to know that over a period of time. And until we study what we implement and hold it against some barrier of expectation, then we don’t know.

And you think we dropped that ball over the years?

I think we did in the past and we’re trying to correct it now. You can’t have interventions any more unless you can prove that you can monitor the outcomes and you can tell us the results. And that poses a problem for some people—particularly mom-and-pop, community-based prevention programs and initiatives—because they require more rigor and more skill sets. So that means we have to do far more training. But the people we train have to be prepared to receive the training. So, just anyone can’t step up to the plate.

You say “community-based,” but it’s also Black-focused groups. They’re often smaller when they’re focused on minorities, and they say, “Man, all of this new paperwork, all of this new rigor, I can’t do it all and compete for the grant and actually run my program.” What’s the solution to that?

Step up to the plate, or identify in your community people who can do it. I have been involved in this epidemic from the very beginning. I mean, Phill Wilson [the Institute’s executive director] was the person who trained me to do my first outreach—“Hot, Healthy and Horny.” [Laughs.] So I go back to the beginning. And I can tell you that a lot of good programs—in terms of how they look, how they sound and how people reacted to them—were promulgated through the early 80s and 90s. But can we tell you specifically how people modified their behavior? How they changed themselves so that they did not become infected? Could we tell you about the number of people who were not infected at the time we did the training and the number of people who got infected over a period of time? Or who remain uninfected to this day? No. But that kind of information is critical to our understanding whether or not interventions work. So we have to re-posture how we approach doing prevention.

I hear you, but what would your advice be to those who would say, “I’m stepping up to the plate. There’s just more than I can do.” What would you tell them?

At this point in time, it’s too critical. It’s too critical to let people off the hook with “it’s hard.” Keeping people alive is not the easiest thing in the world to do. And we’re up against not only people’s sexual and drug use behavior, but people have other issues in their lives. Some of their issues may be education, some of their issues may be employment, some of their issues may be as fundamental as housing and nutrition. And in the context of all of that, we’ve got to make sure that whatever we do around HIV or STD prevention gets in the psyche of people and competes on equal footing. And if it’s not competing on equal footing, then we’re not doing our job.

So we’ve got to create prevention interventions that impact people emotionally, and raise people’s level of consciousness about modifications of their behaviors that might lead to risk.

Does the administration get the racial implications of the epidemic?

Oh, I think we do. And I think the racial implications—and also the ethnic and the nationality piece, and then you couple that with religious norms and notions that people have—makes it very, very, very complicated to design interventions that can take all those factors into account. And that’s where our big challenge comes in. We’re not a monolithic society. We may speak English by and large, but we’re not monolithic. So it’s important that we keep community-based activities in place, so that they can design interventions in part around the indigenous psyche, value systems, norms and mores and connect with the people we’re trying to speak to. That challenges us both technically, in terms of bringing the right people together to design the right interventions, but also monetarily, because it means we need so many layers and so much diffusion of interventions that often times communities can’t respond.

A lot of people—the Black AIDS Institute included—were very up in arms at the vice presidential debates, when the vice president made this comment that he didn’t know the stats about Black women and HIV. Has too much been made of that? That’s part of why I’m asking about whether the administration gets the racial dynamics, because what came out of that was this outcry: “They don’t get it!”

No, I don’t think we’ve made too much of it. It was a very important point to be made. I think it was very important in the conversation about domestic HIV and AIDS. But I also think that was a purely political arena where that took place. I would challenge the average person, even who works in public health: Do they really know the impact of HIV on the various racial and ethnic groups in their own communities? And I would venture to say that most don’t. They may say, ‘Well, I think it impacts mostly Black people.’ But what does that mean? Who among Black people? So unless you’re working this, you generally don’t know how the epidemic unfolds, as it impacts a specific racial or ethnic group.

A lot of folks feel like the administration doesn’t take prevention seriously. What about the administration don’t we know? Do you think it’s a bad rap?

First of all, I think it’s a bad rap that the administration doesn’t take it seriously. They do. HIV is not the only area in the budget that gets cut. A lot of health programs across the budget have gotten cut. So we’re all sort of sharing the burden of the war and domestic security and other things like that. I think that people thought that the Administration was going to come in and dismantle our AIDS apparatus that has developed over the last 25 years. That has not happened.

So clearly there is support. I think what we also see … is a feeling of normalizing HIV, and not keeping it in a glass bubble, if you will. There are other conditions and diseases that people die from in America that are very comparable to HIV—if not surpassing. I mean, we still have cancer, and all forms of cancer challenge us nationally. Black people suffer from cancer at a rate that’s disproportionate. We can talk about hypertension and heart disease and things of that sort. So, is one illness more important than another? I say no, all illness is important. I fight for HIV. I believe in our responses to HIV. But I can’t also ignore the fact that there are other health conditions that are challenging people. And many of those other health conditions are challenging people with HIV….

This is not easy. There are few people who present with HIV and that’s their only challenge. When we look at poverty, we look at HIV. When we look at education, we look at HIV. And no matter what we have done in the past in terms of giving people information about HIV, sex is a real powerful thing in people’s lives. And I think the challenge we have is not that people won’t use a condom, it’s that every time sex has the potential to occur condoms aren’t available and people make decisions about what risks to subject themselves to. And it’s at that point that we find out whether or not our prevention messages were powerful enough.

So ultimately there are limits to prevention, there are limits to what we can accomplish?

Well, there are not limits to prevention; there are limits to people’s capacity to consistently respond to the messages we have given them. I think we have empowered people with the messages. I think we get challenged by how people interpret the message and incorporate it into their lives as a whole. That’s a bigger challenge.

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