Elizabeth Pisani’s The Wisdom of Whores – Bureaucrats, Brothels and the Business of AIDS is a great book (along with a great website ). Elizabeth Pisani is an epidemiologist with years of experience working on HIV/AIDS (or sex and drugs, as she puts, which sounds a lot, well, sexier) at a variety of agencies, including UNAIDS. The book is the story of her frustrations at the way the international community, national governments, NGOS and AIDS activists have dealt with the epidemics, as well as her hopes in some of the progress made.
I got interested in the book when I read an interview Pisani gave to the Guardian. The interview kinda billed the book as a controversial work where Pisani would be the mean lady who said people got AIDS because of their stupid behavior and not enough was being done because of political correctness. So, I was ready to get really pissed off with the book. That has not been the case at all.
Elizabeth Pisani is a scientist and that perspective is pervasive in the book. That’s a good thing. I much prefer sober, "just the facts" perspective to touchy-feely stuff. Actually, one of the main frustrations that Pisani deals with in the book is the fact that AIDS had to be made about innocent wives and children for the international community to gear into action, as opposed to the real populations at risk in most parts of the world (except Africa, and she shows that even in Africa, the innocent wives and children trope does not work, as the data show): drug injectors and people who buy and sell sex.
To me, precisely because the book is data-driven, it was not controversial. My reaction was more, "well, if that’s what the data show, so be it." But also, I think, the book was billed as controversial because Pisani calls things what they are: penises, receptive or insertive anal sex, etc. and she does spend a lot of time describing her study in red light districts of Jakarta and other (mostly Asian) place. She discusses the brothels, the warias (transgendered male prostitutes) and rent boys, the drug injectors. She does spend a lot of time describing that world that a lot of people would rather never hear of: the stigmatized, the marginalized, those we can safely ignore and those that don’t get politicians votes come election time. Doing nice things for whores and junkies carries no political rewards. Doing things for innocent wives and children does. So, that’s what has been done with HIV/AIDS and this has been a tragic mistake.
But these descriptions are unvaluable and fascinating because we never read about them. If you read about HIV/AIDS, you will read a lot about Africa (which does make sense since the high rates of infection in the general population are to be found in Eastern and Southern Africa). The problem is that the African patterns of infection have been assume to apply everywhere, especially Asia, where that is just not the case. So, the solutions and programs suggested are inadapted.
The programs needed in Eastern and Southern Africa are not those that are needed in Asia. In these parts of Africa, AIDS does affect the larger population (Zambia, which I visited a couple of years ago, the infection rate is at an appalling 16% of adult population) but that’s just not the case in Asia where most of the solutions described by Pisani involve programs to distribute condoms, lubricants and clean needles. It is also one of Pisani’s other frustrations: we know how HIV is transmitted (biologically, that is), we know the types of behavior most likely to facilitate this transmission, so, we know what kind of prevention is needed. And yet, there is too much focus placed on treatment, rather than preventing people from getting infected in the first place.
Another thing that definitely comes through as Pisani tells the story of her peregrinations through Jakarta, trying to collect good data to design good public health policy, is that, whether she likes it or not, she comes across as someone who really does care about all the junkies, whores and warias she meets along the way. Her scorn is reserved for other people: UN bureaucrats playing the Bullshit Bingo (lining up sentences in a report or a grant proposal that will get you money but say rigorously nothing – grant writing is art of bullshitting… Hey, I work in academia, I know what I’m talking about here!) or do not want to call things what they are because of who might get offended, religious conservatives who lie and work their hardest to prevent good prevention or good policy because it offends their religious sensitivities to imagine that people *clutches pearls* actually enjoy having sex or shooting up drugs. But don’t think the liberal crowd, the NGOs or activists are off the hook either. Anyone who distorts the data (and Pisani does not let herself off the hook here either) for their own purposes and blocks good prevention is torn a new one, and rightfully so.
Pisani has no patience for distraction, a major one being that AIDS is a gender / development / poverty issue. Pisani shows that this liberal idea, favored by a lot of NGOs and UN agencies and other donors is a distraction. First, it’s a distraction because first, you may have the causality wrong (AIDS causes development / gender issues rather than the other way around), second, as shown in the book, even in Africa, that’s not always the case, and third, because, again, that gets in the way of common sense prevention which should be the main focus, along with treatment for the already infected population. But again, focusing on women and children makes the AIDS issue more palatable to donors than those filthy whores, junkies and fags, so, Pisani and her colleagues at the AIDS Mafia, as she calls them, played that game too. After all, once you have the money, you can still get stuff done.
And, of course, I particularly enjoyed the chapter blasting the Bush administration and its faith-based initiatives and PEPFAR (President’s Emergency Plan for AIDS Relief). Although she does credit the Bush administration for putting money on the table, Pisani makes mince meat of the Bush and his religious nuts crowd for their hypocrisy and nonsensical attitude. She deals swiftly with Virginity Pledges and the creepy Virginity Balls and the whole family values crowd.
Finally, Pisani has also no patience for the workings of the international community and civil society, the demands that donors put on local activists, the circuits of money distribution which end up sometimes producing ridiculous policies: like having an AIDS program in East Timor when there is no AIDS problems in East Timor (although there are other problems that would need funding but don’t get it).
Again, let me state: when was the last time you read an epidemiology book that was a great read, straight to the point, data-based, sometimes fun, but always informative. It was funny that on a flight to New York, last weekend, the guy seating next to me was reading a book about Paul Farmer and I had my copy of WofW out, best on-board discussion I had in a long time. I would love to hear what Pisani thinks of Farmer’s approach.
And to conclude, Pisani is more of a sociologist than she would probably admit because her book seamlessly merges the social and the epidemiological. She acknowledges that, of course, science does not operate in a vacuum. That can be a problem when the political screws the most basic tenets of public health when it comes to prevention (distribute condoms and clean needles). But when she describes the different social (as opposed to biological) patterns of AIDS transmission (strings as opposed to networks), she’s a practicing sociologist. Not that I’m complaining.
A great read. Highly recommended.
My own photos taken in Zambia on AIDS:
Fighting stupid beliefs such having sex with a child will prevent or cure AIDS:
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