The wisdom of whores
by Steve Danzis
[ bookreviews ]
It may seem like old news, especially in this time of economic crisis, but the AIDS epidemic continues to rage in many regions of the world. Sub-Saharan Africa alone has about 22 million people infected with the HIV virus. Nearly six million of them live in South Africa, where President Thabo Mbeki blocked AIDS programs for years because he rejected the idea that HIV causes the disease. Mbeki's probable successor is not much more enlightened: During his 2006 trial for allegedly raping an HIV-positive woman, Jacob Zuma, leader of South Africa's ruling party, claimed that he cut the risk of infection by showering after they had intercourse.
In The Wisdom of Whores, Elizabeth Pisani portrays the epidemic as simple yet maddeningly complex. Simple, because it could be brought under control by widespread condom distribution and needle-exchange programs. Complex, because politics and ideology continue to hinder such efforts. An irreverent and impassioned writer, Pisani takes aim not only at Third World politicians such as Mbeki and Zuma, but also at the humanitarian programs of Western countries and nongovernmental organizations.
Pisani began her career as an epidemiologist in 1996 at the headquarters of UNAIDS, a newly formed United Nations AIDS organization. Although she and her colleagues never made up facts, they often presented them in the worst possible light to gain the attention of donors. This approach was wildly successful: the amount of money donated to fight AIDS rose from around $300 million in 1996 to $10 billion in 2007. Yet Pisani argues that the vast increase of funding became counterproductive, creating a "world where money eclipses truth".
The actions of the Bush administration illustrate how money and ideology can distort policy. In 2003, President Bush announced the PEPFAR plan, which called for the United States to spend $15 billion over the next five years to fight AIDS in developing nations. Pisani gives Bush credit for greatly increasing the funds available for testing and treatment of poor people. However, the ideological strings attached to the plan hampered efforts at prevention. The US refused to fund needle-exchange programs, which limit the transmission of HIV among intravenous drug users who would otherwise share needles. The administration also pushed abstinence over condom distribution, even though numerous studies have shown abstinence-only programs to be ineffective.
Moreover, countries that accepted PEPFAR funding had to commit to abolishing prostitution instead of regulating it. This provision made it difficult to provide life-saving information and services to sex workers and their clients. Ironically, the first director of the Bush plan gained notoriety in 2007 when he was implicated in the "DC Madam" prostitution scandal.
The most interesting chapters in The Wisdom of Whores cover Pisani's field work in Indonesia and other Asian countries. She was hired by the Indonesian government to help monitor how HIV was being spread. As she explored the brothels, gay bars and shooting galleries of Jakarta, she realized that many of her assumptions needed to be revised: "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 aeroplanes and Muslim fundamentalists who run protection rackets for brothels."
The "women with penises" Pisani refers to are the waria, transgender sex workers who consider themselves women and mostly have sex with straight men. Although the waria are an important route of HIV transmission in Indonesia, the government had largely ignored them until Pisani's arrival. By extensively interviewing waria, she learned how the complexity of their social status can affect AIDS programs. For example, waria often avoid seeking treatment because the government health services make them use male wards and clinics, which they find humiliating.
Pisani was frustrated by how difficult it was to get politicians to act on her advice. Reluctant to be seen helping prostitutes and drug addicts, they often diverted AIDS prevention money to populations that had a low risk of contracting HIV. Perhaps her most controversial suggestion in the book is that authoritarian governments, such as China's, are better able to deal pragmatically with AIDS because they don't have to answer to voters. While it is true that China now has sound policies, the government essentially ignored its AIDS problem before 2003. This about-face was prompted in part by international outcry over China's cover-up of the SARS epidemic, which should remind us of the benefit of public accountability.
Pisani sees hope in the work of large private donors such as the Bill and Melinda Gates Foundation, which is committed to evidence-based programs and has huge resources to implement them. Whether funding comes from governments or foundations, the struggle to end the AIDS epidemic will be difficult. Just recently, Pope Benedict XVI traveled to Africa and gave a speech in which he rejected the distribution of condoms to fight AIDS, declaring that it "increases the problem." Clearly the battle between ideology and sound policy is far from over.