A few months ago I wrote a review of Elizabeth Pisani's book The Wisdom Of Whores which recounted her work combating the AIDS epidemic in South East Asia. In the book she talked candidly about issues that most people are still afraid to speak about openly when it comes to the disease. A great deal of what she talked about is the need to ensure that the world doesn't become complacent when it comes to the issue of AIDS prevention.
As more and more drugs have come along that can extend a person's life once they have contracted the disease, and money is being poured into searching for a vaccine, less and less is being said and done about the nitty gritty of AIDS prevention. Most political and religious leaders would rather talk about how much money they are spending on a vaccine instead of talking about making sure intravenous drug users have clean needles or transgendered prostitutes have condoms.
Even sillier are the ones who start postulating about how things as unrelated as Global Warming, are causing the virus to spread. While there is some truth to the fact that poorer countries are hit harder by AIDS, economic factors are not the major contributor to the spread of the disease that people would like to think. For the disease to be transmitted it still requires an exchange of blood to occur between an infected and an uninfected individual. Unprotected sexual activity and sharing dirty needles are still the two main ways the disease is spread.
Elizabeth Pisani called me from London England on Tuesday July 8th to talk about the Wisdom Of Whores. She had just retuned from a three week tour or the United States promoting the book there. When we had set up the interview she had suggested waiting until after she was done with her book tour of the United States so we could talk about the reactions to the book. Things didn't quite go as planned, as you'll see, and we ended up having a rather free wheeling discussion about the state of HIV/AIDS prevention and policy around the world.
You've just finished an extensive book tour of the U.S. for Wisdom Of Whores, and you're still among the living, but I'm guessing it wasn't without its moments.
Well to be honest, there was almost no public reaction at all. (laughs) Which in itself says something. There seems to be a huge amount of reluctance on the part of the media to deal with confrontational issues.
Well what about reviews - the New York Times and the other big papers - nothing?
Nothing - there was only one review that has been published in the mainstream press since the book was released at the beginning of June. That was in the Philadelphia Enquirer, and it was a very positive review too. There has been quite a bit in the blogsphere though, and I had some radio interviews on National Public Radio (NPR), but that was it.
Even in cities like San Francisco, where you'd think they'd notice a book about AIDS, there wasn't anything at all in The Enquirer or any of the papers. I did have a meeting with the head of one of the grass roots organization in San Francisco, and that was good. He and I don't always agree on everything but I have immense respect for the work he and his people have done.
So no, there are no real "Moments" to talk about that happened in any of the public meetings. Interestingly enough though the book is selling better in the States than it is in Britain where I've had all sorts of press. It was strange to go from being in the pages of The Financial Times to nothing - but there it is.
Where I did get some reactions was in the private meetings at places like the World Bank, The Gates Foundation, and USAIDS.
Well that was a question I was going to ask you a bit later on - so I might as well ask it now. What has been the reaction of places like that to the book.
I was scheduled to give a sort of brown bag, lunch time talk, with questions and answers at World Bank headquarters in Washington DC. I had been told not to expect many people, maybe ten or fifteen, but it ended up being standing room only - so about sixty people, which was quite wonderful.
What was the subject of the talk?
The interaction between prevention and treatment, and how we in the AIDS profession are still getting it wrong by not focusing our energies where they are truly needed which is on the high risk groups; men who practice anal sex, the sex trade, and intravenous drug users.
I don't get it - way back in the early days anybody I knew who was aware of the disease knew those were the people most at risk, and we also knew how the disease was transmitted - why is it still so hard for people to get that message?
There are really two issues at hand here, one is partially the fault of us in the AIDS industry and the other is the concern over the stigmatization of those in the affected groups. Unfortunately there is a very real concern when it comes to the latter; by saying men who have anal sex, people in the sex trade, and intravenous drug users are the ones most at risk for transmitting the disease you set them up as pariahs. As these are also people who already exist on the margins of most societies, or are a minority already subject to harsh treatment, labelling them most at risk for transmitting the disease increases the chances of them being ostracized.
Knowing full well that politicians weren't going to want to put up money for gays, sex trade workers, and needle users, the threat to people outside the high risk groups was stressed in order to secure any money at all. The trouble is that the money isn't being spent on the areas where it's most needed. It's all very well and good to have programs for people in the low risk groups, but if we don't spend the money on those most at risk what are we really doing to stop the spread of the disease?
For example in the Bronx, the borough in New York City, they've just announced a program where they are going to test everybody over the age of fifteen for the virus. That includes people who have been widows for twenty years and the celibate - people who are at no risk of getting the disease. We already know who are at most risk, and wouldn't the money be better spent on testing them, providing them with treatment and setting up programs to stop them from spreading the disease?
In New York City one in four of gay men who are coming in to be tested are not only HIV positive but they are already in the throes of full blown AIDS - which means they are waiting for symptoms of the disease to show before they come into get tested and by then they are at the most infectious. There's something seriously wrong with that, and its because we're not doing enough to work on prevention.
In Canada we just had the recent furor over a safe injection facility in Vancouver British Columbia - Insite - that the federal government was going to close, but thankfully a judge in British Columbia ruled they couldn't because it provides a health care service. The attitude from the government was one of - I don't care about junkies.
Right and that's the vicious circle people working in the world of AIDS are dealing with. If there was ever an under serviced area in the world right now it would be the East side of Vancouver. I've seen some pretty bad spots in the world and that's just horrible. The people there are trying so hard to do something but they have so little to work with. Insite is only able to cope with 5% of the people injecting on the street.
Here's an irony for you, when the people opposed to Insite found out that figure they tried to make it part of the argument against keeping it open by saying, well they can't be doing much good if they're only servicing five per cent of the population. Of course all that means is they don't have the resources to do any more.
Well you can make statistics say anything can't you?
Oh yes, you can torture numbers to say what you like easily enough, but it doesn't change the reality of the situation. We know that there are only very specific circumstances required for the HIV/AIDS virus to be spread; an infected person, and uninfected person, and an exchange of bodily fluids. So obviously you have to prevent the spread of bodily fluids from the first to the second.
Yet, I was at USAIDS saying just those things while I was in the States and the director says to me: "I never thought of it that way before". Maybe I'm a little too Pollyanna, but I hope that by constantly keeping pressure on the people delivering services that we can at least get them to spend the money in the areas where it's needed. Go ahead and do all your studies and set up your programming with the other groups, because of course its needed, but don't do it at the expense of the people who are at most risk of contracting and spreading the disease. Unfortunately that's the situation we are currently in.
Even before I read your book I had the impression that people are very defensive when it comes to AIDS prevention - and any critical evaluation, no matter how constructive, is treated like an attack. Is this a valid impression and if so how did this fortress mentality come about?
I'd like to say it's not true, but unfortunately it does exist. There are two types of people who get involved in HIV/AIDS work; those who give a shit, and those who are there because that's where the money is. Those of us, like me, who are in because we give a shit want to to believe we know what works. We know the communities we work with and how to best reach individuals within it - who is going to react positively to what incentives to use what prevention methods. I think if we didn't have that belief we wouldn't be able to keep doing what we are doing - you have to have the feeling that you're making a difference otherwise how could you keep on doing it?
The result is we only want to hear good news, we don't want somebody like me coming in from the outside saying well you know this isn't working because of such and such. It's so hard to get funding for programming that you fear that anything negative that comes up will adversely affect the programming you know that is working well, or that you believe should work.
For example I know, I firmly believe that there is a co-relation between preventing the spread of other Sexually Transmitted Infections (STIs) and preventing the spread of HIV/AIDS but the data just doesn't add up. No matter how I look at the statistics I can't prove that working on one helps the other - yet I know that it has to be true.
Of course the second group of people, those in it for the money, want to show they are doing a good job so they can keep on getting their funding and have jobs for themselves.
Recently there's been talk by the Canadian government of refocusing the direction of their HIV/AIDS funding away from grassroots organizations towards putting it into research on a vaccine. To be honest I'd never even heard talk of a vaccine before this - how realistic a goal is that?
The vaccine has become the latest pet project, the Gates Foundation has been sinking a lot of money into it. While I wouldn't say we should give up on the vaccine, it's so far been a very disappointing failure. Of course it's very safe politically, because you don't have to say anything about the money being spent on anything controversial like needle exchanges in prisons, but it looks like you're doing something. If I may be so bold, for the amount of money that Canada would be putting up, it wouldn't really accomplish much and would be better off spent elsewhere. Huge amounts of money are already being spent on it by Gates and the World Bank.
Yeah well Gates has more money than our GNP, so if he's putting money into it what difference would our few dollars make?
How are other countries dealing with the three high risk groups. Especially countries that we in the West might consider resistant to talking about sex and drugs.
Well one of the biggest success stories working with the sex trade was in Cambodia, where the government had worked out an arrangement with the brothel owners so that condom use was being promoted among all the workers. Unfortunately the US government, under pressure from the International Justice Mission (IJM), who I call Cops For Christ, threatened to remove Cambodia from their donor list if they didn't crack down on the sex trade in the country.
Cambodia did have a serious problem with child prostitution, that was simply shocking, and that needed to be dealt with, but instead of just targeting those specific cases, the government was forced to close down the whole system. The result was that the all the brothels were raided, the girls were raped and had all their savings and gold stolen from them by the cops, and the trade has been driven underground where there is no government control or regulation. It hasn't stopped the sex trade.
(In her book The Wisdom Of Whores, Ms. Pisani goes into details about the events in Cambodia and the problems the IJM create where ever they go. The girls they "rescue" from prostitution have no means of making money and are dumped on local service agencies who don't have the facilities to deal with them. IMJ are despised and distrusted by the local police and the sex workers for making the problem worse not better.
The girls are forced to take re-education courses - like sewing - for six months during which time they are not paid. There are many cases of them using ladders and rope made out of their bed sheets to escape the shelters they have been sent to after being rescued. As one prostitute put it to the author "Look, if I could afford to be going to school for six months without pay I wouldn't be selling sex".
The final tally is that by the end of 2005 fewer then 1000 girls had been successfully rescued from a life of prostitution, and the IMJ had received five million dollars from the Gates foundation to fight prostitution and the HIV/AIDS it was supposed to spread. On the other hand the Cambodian government's program had ensured that an estimated 970,00 Cambodians had used condoms when they bought sex by the same date.)
The real big surprise is in Iran, where they have set up needle dispensers on the streets of Teheran so that anybody who needs a clean needle has ready access to them. They also have needle exchanges in prisons there.
It's been reported in the Western media that Iran claims they don't have any homosexuals.
Oh, most of the Middle East is still really bad when it comes to the issue of Homosexuality. In fact in Egypt they arrest anyone with HIV/AIDs because they take it as a sign that you're gay, which is illegal. I thought we'd grown up somewhat and were beyond that. It was just as bad in Africa where up until a short while ago in the sub-Saharan area they denied they had any homosexuals at all. Of course there homosexuals are probably no more at risk than heterosexuals when it comes to contracting the disease as it's so widespread.
Africa has obviously been the worst case scenario for the AIDS virus. At one time people were predicting that India was another Africa just waiting to happen - do you know have any information about that situation?
I've not worked on the ground in India since I was a reporter so I don't have any first hand experience but I do know the data and some of what's been going on there. UNAIDS, on the last World AIDS day - December 1st/07 - actually revised the projected number of people infected with the virus downwards by two million, from five to three million. It was a classic case of not looking at the right groups and using misleading data to base their estimations on.
The data that the figures had been based on was collected from a couple of hospitals where all the difficult cases were being referred to, and these hospitals had a large number of pregnant women coming to them with the infection. From that information they postulated that pregnant woman were a high risk group for infection across the country. At the same time they were almost completely ignoring the people in the high risk groups. This of course skewed the original tally badly - it take make it better politically to be able to say that pregnant women were at risk, but it meant nothing was being done for those who really needed treatment.
At one point there was only one web site providing information for people in the sex trade and something like two for homosexuals and one for intravenous drug users - or is that the other way around - at any rate this in a country of close to a billion people.
Thankfully, this is one country where Bill Gates, bless him, has done something useful. He offered the country 110 million dollars on the condition it be spent on prevention programming for high risk groups. When the federal government dithered and held their hands up in horror, he by passed them and went directly to state and municipal governments who gladly took the money and began implementing programming. What's even better is that other states have seen the success they've had and are creating programs based on them.
So now that you're no longer in the sex and drugs business, what are you going to do now for excitement?
Well I don't really feel like I've completely left the business, what with the book and all. I'm still out talking to people about the issues and I'm still doing the occasional consulting work, and reviewing articles for journals. To be honest what I miss is the most is the number crunching - the excitement of discovering something new or finding the proof that what I believed to be happening was actually happening.
Well this didn't turn out quite the way we planned - I still have a hard time believing there's been so little notice given the book in the press and there was so little reaction at all in the States.
Well there was one good story I can tell you, it was during a radio call in show in Illinois on the NPR station. I took this one call from a gentleman who was very much in agreement with a lot the things I had been saying. At one point he said, well wouldn't it make sense to legalize prostitution? What was really surprising was he was a State Senator for Illinois.
Thank you very much for this Elizabeth.
Well I have to say that I had had visions of hearing tales of Ms. Pisani receiving death threats over the phone and being denounced from pulpits across the South or something similar when we set up this interview. Here she was, a woman who took great pride in saying she worked in sex and drugs going to the country who ties foreign aid to their version of morality.
The fact that the book is being completely ignored is probably even scarier than it being the subject of debate or her the object of hatred. Although I'm not sure if it's as scary as hearing that the director of USAIDS had never thought about the correlation between how the disease is spread and how to prevent it from being spread.
(Originally posted July 2008)
Richard Marcus is the author of two commissioned works published by Ulysses Press, editor in the books section of Blogcritics.org and contributor at Qantara.de. He has been writing since 2005 and his work has appeared in publications all over the world including the German edition of Rolling Stone Magazine.