07.23.08
AIDS war
RG
Globe and Mail July 19, 2008
Public health: sex workers ought to know what they’re talking about
What went wrong in the AIDS wars
Stephen Lewis
THE WISDOM OF WHORES
Bureaucrats, Brothels, and the Business of AIDS
By Elizabeth Pisani
Viking Canada, 372 pages, $35
This is an utterly fascinating book. I must admit that it’s been
growing on me since I read it, the arguments and language
reverberating in my mind. Elizabeth Pisani writes with enormous verve
and acerbity, her prose alive with anecdote and metaphor. There is, to
be sure, a certain adolescent touch, delighting in naughty words and
vivid sexual description, but all of that is forgiven in the sweep and
force of the narrative. The Wisdom of Whores is a great read.
The title is meant to convey the variety of sexual experience and the
savvy that attaches to it. The text is replete with references to
“prostitutes, rent boys, pimps and clients … addicts, cops and rehab
workers.” The chapter on Indonesia alone is an astonishing foray into
the world of female, male and transgendered sex workers, all of them
imparting wisdom on AIDS. Even in the preface, Pisani talks of a trip
through several Asian countries where “I encountered a world of women
with penises who sell anal sex to men who are completely heterosexual.
I found men who buy sex from women and sell it to men. I found heroin
addicts who fly airplanes and Muslim fundamentalists who run
protection rackets for brothels.”
Yes, some of it is designed to shock. But as the pages turn, the
interlocking universe of bureaucrats and sex work and NGOs and
agencies yields fascinating insights into the pandemic. It would be a
great mistake to discard Pisani because of the bizarre or the
uncomfortable. There are many home truths to be found in the most
unlikely of places.
He book is also a compelling challenge to most of the orthodoxy that
clutters the world of HIV/AIDS. Although the great majority of
material is drawn from Asia (primarily Indonesia, where the pandemic
is relatively small), rather than Africa (where the pandemic is a
nightmare), Pisani still manages to wander the landscape of
controversy.
Pisani is a journalist turned epidemiologist. She’s worked or
consulted for a kaleidoscope of international organizations in a great
many countries, allowing her to speak with first-hand knowledge, and
to make a number of frontal assaults on conventional wisdom. Most
important, perhaps, is her exasperated assertion – gaining increasing
credibility in the argumentative world of AIDS – that the
international response has been wrong-headed: The assumption that a
generalized pandemic sweeping through a country’s population, as in
Southern Africa, would necessarily show a similar pattern in a country
like India or China or Indonesia just isn’t true. The pattern outside
of Africa is a series of concentrated epidemics among “high-risk
groups,” men having sex with men, or drug injectors or sex workers,
and there is very little evidence that the virus will infiltrate the
broader population.
Now nothing is absolute in the world of AIDS, but Pisani’s argument,
if even marginally accurate, has huge implications for the response.
If the resources, especially for prevention, are applied to a
population as a whole, where the risk of contracting AIDS is minimal,
rather than targeting the high-risk groups, then not only is money
wasted, but HIV spreads wantonly through these hard-to-reach
categories.
There’s just no question that the hotshots of the AIDS establishment
have resisted Pisani’s thesis (also advanced by others of repute) for
many a year. It’s monumentally irresponsible. When the head of
HIV/AIDS for the World Health Organization recently made statements
much in line with those of Pisani, he was forced into a humiliating
retraction by vested interests in other parts of the UN system.
The beauty of The Wisdom of Whores is that it leaves no AIDS stone
unturned. The chapter on injecting drug use is stunning: I have not
read before so trenchant a defence of “harm reduction.” Pisani summons
an overwhelming weight of evidence from around the world to
demonstrate the validity of clean needles and methadone as preventive
tools to stem the virus among injecting users.
On the issue of resources, she’s scathing in her indictment of the way
the money is deployed (an especially delicious anecdote is the story
of East Timor, which, upon independence, received $2-million from the
United States to fight AIDS, and there were exactly seven infected
people in the entire country).
On the issue of abstinence, she’s appropriately savage about the
perverse policies pursued by right-wing religious groups and the Bush
administration: There is no doubt in her mind – and again, the
evidence is summoned impressively – that ideology has been permitted
to trump science, with disastrous results. In truth, it is beyond
criminal the way the Bushites, in the mindless embrace of abstinence,
have undermined the use of condoms.
On the issue of numbers, Pisani insists that she never saw any
deliberate inflation of the data, as has been charged by others
(myself included). But she admits to the use of percentages by UNAIDS
as a “beat-up” technique to raise international alarm in the hope of
generating money. It was clearly a successful (if dishonourable)
strategy: Resources have leaped from roughly $300-million annually in
the late 1990s to $10-billion in 2007.
On the issue of testing, she has very little patience for the human
rights view that all testing should be voluntary. Where Pisani is
concerned, public health transcends human rights, and testing should
be far more broadly applied. She effectively argues that there are two
“rights” at issue, and the right of the individual to voluntary
testing should not be permitted to compromise the rights of the
community against infection. I will concede that even though it
strangles me to say so, I see increasing legitimacy to that view.
On the issue of the tension between treatment and prevention, she
comes down firmly on the side of prevention. Pisani argues that while
treatment brings down viral load (the amount of the virus in the body)
so that transmission from the infected to the uninfected is
dramatically reduced, the fact remains that transmission can still
occur, and over the long run this will continue to drive up the number
of cases. It’s an interesting point, but it’s thin gruel, and I’d take
issue with the theory. There’s no reason why treatment and prevention
can’t be done in tandem if the powers-that-be determine to do so. It’s
not a Hobson’s Choice.
On the issue of Africa, the argument becomes complicated, and
unfortunately Africa receives short shrift in The Wisdom of Whores.
But that doesn’t stop Pisani from being unequivocal: “The world’s
greatest and most shameful monument to failed HIV prevention [is] the
AIDS epidemic in Africa. In Africa, we’ve made every mistake in the
book.”
For Pisani, the fraudulent approach to Africa resides in describing
AIDS as a poverty and development issue. Nuts, she says (almost
literally). It’s a problem of sex, a collectivity of simultaneous
sexual partnerships, uncircumcised men and untreated sexually
transmitted infections. And because African leaders won’t face up to
sex, and the international community, for fear of being called racist,
won’t challenge Africans on matters sexual, everyone hides behind
poverty and development.
There’s a touch of truth in that, although the African leadership has
graduated from its state of denial, and confronts sex and stigma much
more openly. The real problem lies in the lackadaisical and incestuous
international AIDS establishment that has lost the energy and
creativity to wage the battle.
But where Africa is concerned, Pisani doesn’t stop at one critique.
She makes a point rarely made, and I must admit that it gave me pause.
Using an artful epidemiological calculus, she argues that it’s by no
means just men who have several simultaneous sexual relationships;
it’s also women. And to say, therefore, that the pandemic is driven
solely by male sexual behaviour is to miss a large part of what’s
going on.
Now, I don’t think that Pisani gives nearly enough credence to the
absence of female sexual autonomy in relationships, married or
unmarried. Nor does she come close to sufficiently acknowledging the
malignant role of gender inequality (it’s a lamentable lapse that
nowhere in her chapter on Africa is there mention of rape and sexual
violence as vectors of transmission), but she does have a point, and
in the bizarre construct of AIDS, every postulate must be examined.
The Wisdom of Whores ends with the desperate question: “What the hell
difference are we making anyway?” I ask myself that 10 times a day.
The sad, sad truth about the Pisani book is that the rude language and
controversial nostrums will allow it to be dismissed by policy makers
at all levels. But it should be mandatory, not voluntary, reading:
Pisani is lucid, colourful, insightful and impatient. In her last
chapter, she says quite plainly that we know what to do and we’re just
not doing it. She’s right. The worst thing that’s happened to AIDS is
that the same tired, intellectually ossified bureaucrats in
international aid agencies, in many governments, in multilateral
financial vehicles and above all in the United Nations, are calling
the shots.
Elizabeth Pisani is a far straighter shooter than most of them put
together.
Stephen Lewis is the co-director of AIDS-Free World, a new advocacy
group in the United States, chairman of the Stephen Lewis Foundation,
and former UN envoy on AIDS in Africa.