In her book, The Wisdom of Whores, epidemiologist Elizabeth Pisani explains how we could diminish HIV in most of the world, with only a few simple steps. Because, over the years, politics, ideology and cash have bulldozed through common sense and scientifically proven solutions for this global task. The Wisdom of Whores is both a riveting exposé of the AIDS industry, and a penetrating analysis of where we have gone wrong in fighting this disease.
How it started
AIDS came to Pisani’s attention in New York in 1981. Headlines in newspapers screamed about GRIDS: Gay Related Immune Deficiency Syndrome. The disease was renamed Acquired Immunodeficiency Syndrome (AIDS), when drug injectors, haemophiliacs and Haitians had been added to the list of ‘victims’. By 1995, more than one out of ten adults was infected with HIV in Botswana, Malawi, Uganda, Zimbabwe and Zambia. At that time, it was known that there was plenty of risky sexual behaviour going on throughout sub-Saharan Africa, as well as in Brazil and several of the Caribbean islands. It was also known that drug injection was on the rise in some parts of Eastern Europe, and that Asia’s sex industry was huge – much bigger than its condom industry. So, there were far more signs of risk factors for HIV/AIDS, than signs that anyone was doing anything about them.
Beat-ups and babies
In 1995 less than US$250 million was spent on HIV/AIDS globally. This was not enough to extinguish HIV. More money was needed, which meant convincing rich countries that they should worry about AIDS in poor countries, followed by convincing the governments of poorer countries to spend money sensibly to decrease HIV.
How could rich countries be persuaded to raise money for AIDS? By making them feel the heat of the spread of the epidemic and by painting a compelling picture of the devastation the disease was leaving behind. To attain this, Pisani and colleagues used two methods: ‘beat-up’ and ‘babies’. In her book she explains beating it up as making a big, interesting, dramatic story out of something that may actually be rather mundane, by presenting numbers in their worst light. Beat-ups were thought to be justified and necessary in order to catch attention for the spread of HIV. Because it was believed that effective prevention in countries could save hundreds of thousands of lives.
Then the baby method: as HIV was not going to rage through billions in the ‘general population’, and governments do not like spending money on sex workers, gay men or drug addicts, the truth had to be translated into something that governments might care about. Politicians are always happy to do nice things for innocent women and babies. It was argued quite truthfully that men who inject, have sex with one another, or buy sex, are likely to pass HIV on to their innocent wives. Once innocent wives were infected, it was implied, HIV would spread through the ‘general population’.
To know is not to do
Both methods worked: HIV/AIDS was put on the policy agenda. Money started to roll in. Hallucinatory amounts of money: from US$250 million in 1995 to US$30 billion in 2008. However, these amounts of money could not stop HIV from spreading and AIDS from causing deaths. Why? Information from surveillance systems was not put into good HIV prevention programmes.
In Wisdom of Whores Pisani explains: when she started a job as a HIV surveillance expert in Indonesia, she wanted to help map the landscapes of HIV/AIDS risk factors, measure the risk and then work to reduce it. Work was done pretty well at the first two, but there was miserable failure at the third. HIV infection had hit 18 percent among Jakarta’s prisoners in 2000 for example, but by 2004 there were still no HIV prevention programmes in the city’s prisons, let alone any care for infected prisoners. A reason for the failure to turn good information into good HIV prevention programmes can be explained by the fact that people who collect public health data, are not the people who make policies.
The gap between those who have the information and those who make the decisions is wide. In a country like Indonesia HIV surveillance staff members are ‘nobodies’; they work on a stigmatized disease in an unimportant ministry. Surveillance staff members do not have access to policy-makers, and even if they did they would not have the skills to convince them to take on difficult challenges like ‘doing nice things for junkies’, because this does not coincide with the values and beliefs of electors and policymakers. This is another important reason for the failure to make good HIV prevention programmes based on good data.
Pisani describes the consequence of the failure to turn good information into good HIV prevention programmes very well in the following example. She was tagging along with a team from the statistics bureau in the red light district of Jakarta when she was almost assaulted by Lukman, an official boss of the district. In former colonies a white face is often wrongly deemed to be in charge, and soon she found herself hauled up before Lukman. ‘T-shirts!’ he bellowed. ‘That’s all we ever get from you. T-shirts! Out, the lot of you!’ Lukman’s red light district had been subjected to surveys three times, under the earlier system run by the University of Indonesia. The researchers had said that the surveys were necessary to plan HIV prevention programmes and they had left T-shirts with anti-AIDS slogans as a thank you to survey participants. But Lukman did not want T-shirts for his girls, he wanted condoms and a health centre – regular screening and treatment for sexually transmitted infections at the very least.
Catching up with reality
In her book Pisani describes how international organisations developed HIV/AIDS prevention programmes, but failed to implement them because they matched poorly with local realities. An example is peer education, which was embraced ‘almost like the gospel’ by the AIDS industry. Peer education worked very well in gay bars. However, peer education does not work with sex workers, because there is usually much rivalry among the girls. Pisani experienced that peer education is not successful with drugs addicts either. She visited the drop-in centre for drug users Talenta, staffed mostly by ex-junkies. Well, supposedly ex-junkies: Pisani caught one of the staff on drug injection.
Another example of a HIV/AIDS policy from an international organisation that failed is GIPA, which stands for Greater Involvement of People with AIDS. The organisation is based on ‘The Community’: involvement of people infected with HIV in planning and delivering HIV prevention and care services. But being infected with HIV does not glue people together if their backgrounds are too disparate. Support groups for HIV positive women in Cambodia often broke down because infected housewives did not want to talk to infected prostitutes. Like a facilitator from a support group explained: ‘If a woman starts telling her story and it is clear she was a sex worker, you can see the faces of the others change. They blame [the sex workers] for infecting their husbands. So they think: I am infected because of her.’ So this Community theory is not necessarily true for all people who are infected with HIV, any more than it does for sex workers or drug injectors. Being HIV positive does not necessarily make you a good counsellor, any more than being fat makes you a good dietician. Communication skills make people good counsellors, not their HIV status.
How can HIV prevention be successful? According to Pisani there are some simple solutions to fight HIV/AIDS. One is to bombard the places people go to meet new sex partners, like brothels, with condoms and lubricant and create incentives to use condoms every time sex is bought or sold. Another example, is to provide methadone and other oral drugs to help people stop injecting and make clean needles available, also for people in prisons if they need them. In the Wisdom of Whores Pisani also states that it is important to be open about HIV/AIDS and the risk factors: often HIV/AIDS is associated with sinful behaviour, although it is spread by something that most people do. Uganda’s president Yoweri Museveni provides a good example: he talks openly about AIDS, sex and condoms and in this way he is dealing effectively with the HIV epidemic.
Concluding from the Wisdom of Whores: bad politics and the power of money rub out common sense. More sensible decisions, based on sensible reading of well-documented, scientific estimates of who is infected and who is most at risk, should be taken. Science – rather than ideology, religion or the self-interest of bloated institutions – should dictate what to do about HIV.