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.