This interview made me cringe quite a few times but it gives food for thought. Elizabeth Pisani is an epidemiologist specialized in HIV/AIDS. She has worked for the World Bank, the WHO, UNAIDS, the CDC, and other organizations. She certainly has claims to the title of expert on HIV/AIDS. She has recently published a new book with a provocative title: The Wisdom of Whores: Bureaucrats, Brothels and the Business of Aids (someone knows how to make alliterations!). I have not read it (yet) but the interview she gave to the Guardian certainly raised my interest.
The premise of the interview (and, I assume, the book) is that there is a hefty amount of delusional thinking when it comes to the way the international community deals with HIV/AIDS. We spend enormous amounts of money but in the wrong places with the wrong targets.
“Ten years ago, the developing world received roughly $300m a year from the west. By 2007, the figure was $10bn. This year the US alone has budgeted $5bn for HIV in developing countries - and last month the US Congress voted to commit a further $50bn over the next five years. The President’s Emergency Plan For Aids Relief (Pepfar), personally initiated by George W Bush, has been described in Washington as the most successful foreign aid programme since the Marshall Plan”
And yet, what do we have to show for these spending levels? According to Pisani, there is now a whole industry dedicated to HIV/AIDS and spending these amounts, an “AIDS Mafia” as she calls it. But the programs that money pays for are not adapted and may end up costing lives, rather than treating AIDS and saving them. As she states, and this is the first controversial statement:
“”HIV is mostly about people doing stupid things in the pursuit of pleasure or money,” declares the cover on a proof copy of the book. “We’re just not allowed to say so.” She suspects she will never work in the Aids industry again for saying so.”
The major problem is that, in Latin America, Asia and Eastern Europe, the virus spreads mostly through drugs injectors (IV users), gay men, and through the sex trade. These are the population that should be targeted for preventive public health policies. It also means that HIV/AIDS is not going to affect billions of people throughout these areas, hundreds of millions, yes, billions, no. But these categories of people are not exactly the most popular in society. Quite the opposite, when a category of people defined as deviants is affected by something bad, we tend to not care (Ronald Reagan, anyone?).
So, the health community then decided to shift its public strategy away from the deviants (no funding to be had there for research and prevention) towards “innocent” victims: women and children. As Pisani puts it, again, controversially (I think when she was a kid, she enjoyed kicking sand castles)
“”Aids couldn’t be about sex and drugs,” she explains. “So suddenly it had to be about development, and gender, and blah blah blah.”“
Ok, I get it. I am not a complete idiot, but I think the dismissive attitude is misplaced here. I think this is not an “either/or” situation. It is obvious that the fact that people seen as socially deviant affected how governments dealt with HIV/AIDS but development and gender, I think, have a lot to do with dealing with structural conditions. Don’t tell me the sex trade has nothing to do with gender and prostitution. Don’t tell me patriarchy has nothing to do with the treatment of homosexuals. So, she’s right. Enough with hypocrisy: HIV/AIDS prevention policies should be directed at drug users, gay men and sex workers. Like right now. But I also think background structural policies to improve gender equality can’t hurt either.
What is clear is that precisely, in the short term, it hurt:
“The strategy was more successful than she could ever have imagined. “All these obsessively politically correct things started getting introduced.” HIV publications and conferences began devoting more time and attention to issues such as poverty, gender, development, vulnerability, leadership - what Pisani calls “sacred cows” - than to condoms and clean needles.”
Early in the 1980s, one of my sisters, who’s a physician was part of the physician’s union. When the first cases of HIV/AIDS appeared in France, the young physicians in the union decided to do something. At the time, there were no treatment. The only thing to do was to try to prevent the spread of the virus: clean needles and condoms. No other choice. And I remember what a battle it was with the older generation. Yeah, who wants to treat deviants. And I also remember my sister’s waiting room with old ladies from the neighborhood here for general medicine sitting next to the young drug users, obviously already marginalized or on their way. And we heard the same stupid discourse: providing needles would only encourage further drug use; providing condoms would only encourage promiscuity (no more evidence of that then, than now). Better take the moral high ground than be pragmatic and actually do what public health is supposed to be about: stem the epidemic.
And here is another issue I have here, although I agree with the premise:
“There are two distinctly separate Aids epidemics, she says - one in Africa, and one in the rest of the world. In Africa, people are contracting the virus through heterosexual, non-commercial sex. But in most of the world, Pisani claims, the data clearly indicates that the risk is confined to drug users, sex workers and gay men - the very groups that Aids organisations have worked so hard to distance from the problem.”
So, then, doesn’t this contradict the above? Don’t tell me gender and development would not help dealing with HIV/AIDS in Africa (although, when I was in Zambia, ads and billboards encouraging condom uses were omnipresent). The needles and condoms approach seems the appropriate response for the Asian problem (See this segment of the great PBS Series, Rx For Survival on the Condom King in Thailand… you have to scroll down a bit). But what of the African problem? It’s not drugs or the sex trade. Prostitution is very much involved, to be sure. But that again relates to the status of women.
And what of Pepfar?
“”The problem, Pisani says, is that 80% of the Pepfar budget goes on treatment. “Pepfar says great, we’ve got 1.8 million people in treatment. And next year it will be another 1.8 million! That will mean 3.6 million people. It’s exponential - and that’s the biggest question mark over the entire approach to Africa. The more treatment you have, the more infection you get.”“
Huh? According to Pisani, the treatments keep people alive and healthy enough (if they follow the regiment) so that they keep on having sex. The treatments also reduce the viral load, so patients and their sexual partners feel less need for safe sex. And with the treatment, the level of fear of infection (especially in Western countries) is less. That made me cringe, but ok. If she has the data to back that up, then, I can live with the cringe-inducing formulation. Her point, of course, is that treatment is great but we need aggressive prevention. And prevention means to stop being prudish.
“Even the 20 cents in every US dollar allowed to be spent on prevention is wasted, Pisani argues. A third of the prevention budget has to be allocated to faith-based organisations, which refuse to distribute condoms and will promote only abstinence before marriage. The failure rate of “virginity pledge” programmes among young Americans in the US is about 75%; condoms’ failure rate is roughly 2%. Yet Pepfar, Pisani laughs, “claims its policy decisions are ’evidence based’”.”
Is anyone surprised that the Bush administration could mess up on that front too? That religious idiocy would prevail over evidence? I’m always happy to see the mixing of religion with public policy exposed for the sham that it is. But Pisani does not spare the liberal side of things here either: the fact that we do not acknowledge that HIV/AIDS transmission comes from risky, and stupid as she puts it, behavior.
“”I don’t think it’s evil to have anal sex with 16 people in a weekend without condoms. I just think if you do that there’s a high likelihood you’re going to get infected. That’s all. It’s cause and effect. And I think if we can prevent a fatal disease, we should. I don’t get how it’s OK to keep someone alive once they’re sick - but not OK to stop them getting sick. I just don’t get that.”“
See what I mean? Cringe-inducing. I see her point but I find the formulation unfortunate. My issue here is who is her target with this book. Is the right-wing going to latch on to the “stupid behavior” part of it and argue for a moralizing view (as they’ve never stopped doing since the beginnings of HIV/AIDS)?
Anyhoo, I’ve ordered the book, so, expect a full book review in the near future. The book also has a website. And she was kind enough to link to me when I rejoiced at the death of an arch-conservative Archbishop. I am glad to return the favor. I would really like to have a chat with her on all this stuff. I would especially love her opinion on the work of someone like Paul Farmer.
Cross-posted at the Global Sociology Blog
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Great blog
Great Blog.
Well it gives you an idea of what happens when money is tossed. Just about anything.
This includes what Bill Gates does with his foundations, what the world bank does etc.
I would love to know what would happen if ALL of the money were filtered through women. There’s a balance of power for you.
2ndly I don’t believe that money will always last as a viable commodity. Eventually it will be straight resource.
The deal is population control. Until it is enforced worldwide, we will have poverty, gender and racial inequalities, war, ethnic cleansing, honor killings…..
I figured with my batcalculator that the population of the earth would need to reduce to 1.5 billion roughly in order to have a sustainable middle class worldwide, and even then I’m pushing it.
anyhow, more on this tomorrow. Just needed to check in with my favorite blog.
“The great divide in this country is not by race or even income, it’s by those who think they are better than everyone else and think they should play by a different set of rules,” —Bill Clinton
Ugggggggg!
I don’t agree with this at all.
Who’s not acknowledging…
and who is having sex with 16 people in a weekend without condoms?
I can see why.
Speaking of cringe-worthy
jeqal: “Population control” is one phrase that always induces cringes in me. Especially when you say “Until it is enforced worldwide…”
Um, enforced population control??
It isn’t “population control” that’s needed so much as it is - like every other damned thing - the need for women to be allowed to make their own choices and to have those choices respected. Women must be allowed to choose whether or not to marry, whether or not (plus when and how often) to have children. It’s about educating women so they have survival choices beyond marriage and motherhood.
Even if we had enforced population control, that will not end wars, or poverty, or ethnic cleansing, or any of the other evils of the world. Those things have always existed and will always exist, especially in places where women are mere chattel, less important that livestock.
FrenchDoc: Excellent post, and I look forward to your review of the book.
I can almost see where she’s going with the “anal sex w/ 16 people” thing — pointing out that making judgments about how people live is wrong and useless when we have the means to stop/lower infection rates with prevention, as opposed to simply moralizing and treating the infection (at least, I hope that’s it) — but, as you said, very poor formulation. And one that would give the far right plenty of ammo. “Deviants! They deserve it!”
Prostitutes?
I could be wrong, but I believe there are a number of places around the world where a prostitute - be it male or female - has no choice in whether or not the customer wears a condom. Especially in places where the Bush regime has foisted pro-abstinence, anti-condom policies on the NGOs. (Because nothing stops prostitution like telling people not to have sex.)
Look, A Whole World Out There: Thanks fir Reminding Us, Fr. Doc
What willysimmons and PA Lady said. jeqal, not so much.
I especially appreciated your willingness to grapple with the possibility that Dr. Pisana might have some important truths to tell, even though she is framing them through some rather crudely ground lenses, not that such framing is unimportant and can’t blur potential truths.
Like you, French Doc, I’m always suspicious when an analysis hinges on some perception of “political correctness” being the culprit in keeping “truth” at bay. Such nomenclature is almost applied to the liberal/progressive left, and is almost always a misleading oversimplification.
The hesitation to talk frankly about sexual practices is hardly the fault of liberals. And the early worries of those who were leading the way in addressing the “HIV/AIDS crises, that the marginal status of the majority of HIV-infected was likely to become an obstacle to rousing society-wide concern about what was a pending epidemic, or that once roused, those concerns would provoke punitive measures that would only impede early reporting by sufferers, proved to be well founded. The reason that formulations about a day’s worth of multiple anal sex episodes induce a cringe is because of the certainty that what will be aroused in large swathes of the non-inflected population is the kind of fear, censure and dismissal we saw during the Reagan years.
Who could disagree that it is better to prevent infection than to treat it? But are labels like “stupid” the best way to reach people engaged in dangerous behaviors? Maybe, in some cases.
I couldn’t agree more about the importance of gender issues in dealing with the African experience of AIDS. Evidence of this can be found in some of India’s experiences in population control. Much to everyone’s surprise, after years of pushing birth control in villages, providing all forms of it for no charge, and endless awareness campaigns, it was when village women became empowered through programs like the Grameen Bank, that provided them with an opportunity to achieve economic independence, which led to such women refusing their husbands sex without protection that India found atruly effective population control policy.
Great post, French Doc, I look forward to the full review.
Exactly
All the free condoms in the world don’t help unless a woman has the economic power to refuse sex and/or force condom use. It’s difficult to do when your home, your food, your life depends on the man’s income and his goodwill.
Population is a factor of gender equality
and development. Not the other way around. So, the ladies are right: you don’t start with population, you start with gender empowerment (which also promotes development, BTW).
Otherwise… huh… just read Leah’s great comment! (Thanks Leah…(here’s a puppy pix)