Book review: The wisdom of whores

The 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.

*Please send comments to [email protected] or comment online at http://www.pambazuka.org/