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Vol. LXII, No. 50
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Wednesday, December 10, 2008
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Vol. LXII, No. 50
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Wednesday, December 10, 2008
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Elizabeth Pisani is not a shrinking violet. Discussing her new book, The Wisdom of Whores: Bureaucrats, Brothers and the Business of AIDS at a recent Woodrow Wilson School talk, the author and epidemiologist genuflected each time she referred to “the Pope” (outgoing UNAIDS Director Peter Piot), described herself as a“high priestess” among AIDS workers, and more than once used the word “crappy” to describe various government and agency efforts to solve the world’s AIDS problem.
Ms. Pisani, who began as a journalist and later earned a Ph.D. in infectious disease epidemiology from the London School of Hygiene and Tropical Medicine, has provided research, analysis, and policy advice on AIDS to the World Bank, the World Health Organization, and the Centers for Disease Control, as well as to the ministries of health of China, Indonesia, East Timor, and the Philippines. Taking time off from these jobs, she wrote her book, which describes “how the best intentions go astray.” In this “tale of two AIDS” (AIDS in South Africa and AIDS in “the rest of the world”), she talks about how received wisdom and consequent efforts at treatment and prevention have failed. Giving the lie to the notion that “HIV is spread by poverty in Africa,” she noted in her talk, for example, that HIV rates are “stratospherically higher” in Africa’s wealthiest countries than elsewhere.
“Why are we doing so badly?” asked Ms. Pisano in her talk, showing the cost per new HIV infection in the 1980s ($70) compared with the cost today ($2,800). She believes, she said, that there is a need to “repackage the problem,” getting rid of programs like the current $1.3 billion U.S. initiative to teach abstinence in foreign countries. She pointed to successes like the safe injecting programs (particularly in prisons) in the United Kingdom, Australia, and the Netherlands, and educational approaches to condom use as more realistic alternatives.
It’s not a question of money, said Ms. Pisano. Money for HIV treatment and prevention is plentiful, she observed; we’ve now “become so ingrained” that any grant applicant can put “HIV” in a proposal — however unrelated — and get funded. Losing sight of the need to treat HIV like an infectious disease (“$400 million a year, and they can’t put condoms in brothels,” she complained about the Indonesian government) is a major problem. Others include ideological precepts that impede recognition of scientific evidence, institutions that put their own agendas first, and politicians who don’t care about results that will occur after election day.
“Everyone had very high hopes about the Gates Foundation because they’re not beholden to voters,” said Ms. Pisani when asked about the role of private foundations in stemming the AIDS crisis. The slight but intense Ms. Pisani grew even more animated as she reported how she told the Gates Foundation to “treat HIV like Netscape! Crush it like a bug! Whatever you did, do it again!” Sadly (and somewhat ironically, given her talk until that point) she observed that “they brought in old AIDS dinosaurs like myself, who think that AIDS is terrifying. But AIDS is disappearing, and HIV has to be tackled differently. They need to change their thinking.”
Several days after her presentation, Ms. Pisani responded to a query about a recent New York Times article on the plight of AIDS victims in Myanmar. The article reported that the international charity Doctors Without Borders claim that the military junta running the Myanmar government is not spending enough money on AIDS, and that as a result, they are overwhelmed by the numbers of patients applying for treatment and must turn some away. “I can usually find something to disagree with in the Times’s reporting on HIV,” said Ms. Pisani in her response, “but I have to say they are right about this. I would also say that Burma has done far too little in the way of effective prevention. The public health service in Myanmar is full of dedicated hard-working people who do the very best they can under very difficult circumstances. Despite the fact that the HIV surveillance system is relatively strong (and the situation is well defined) and the fact that [head of state] Than Shwe’s wife is a medic, the Junta has too frequently chosen to deny the problem rather than to deal with it. Yes, they’re not doing enough to get meds to the people who need them, and are often deliberately obstructive of NGOs (non-government organizations)who are trying to fill the gaps. But they are doing even less to get clean needles to the tens of thousands of injectors who need them, so they are doing absolutely nothing to reduce future demand for HIV treatment.”
For more on Elizabeth Pisani see www.wisdomofwhores.com/, and www.ternyata.org/.