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The Wisdom of Whores: Bureaucrats, Brothels, and the Business of AIDS

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If Michael Moore were to dress up in women's clothing and prowl through the red-light districts of Jakarta, we might get a book similar to "The Wisdom of Whores." But this author not only has Moore's street smarts and a lively writing style, she also has a PhD in infectious disease epidemiology. Elizabeth Pisani knows whereof she speaks, because she has spent years on the streets and in the dingy bars where AIDS futures are traded.

"Whores" is one of a rare species of book such as Upton Sinclair's "The Jungle" or Jessica Mitford's "The American Way of Death" that has the power to reform an industry. In this case, the author exposes the AIDS prevention industry that sprang up when First World governments started to shovel money into the vital struggle against the HIV retrovirus. Or at least, that's where they should have shoveled it. If you think that the U.S. Government's emphasis on chastity over latex is a great way to spend your tax dollars, you definitely need to read this book.

I was particularly interested in learning why the AIDS epidemic in Asia has not taken off with the same alacrity as it did in South and East Africa.

Elizabeth Pisani may resemble one of Dante Gabriel Rossetti's ethereal Pre-Raphaelite models, but she talks about sex, drugs, and AIDS in the language of her subjects: the sex workers of Indonesia, China, East Timor, and Africa (foreskin soup, anyone?). She describes how governments are wasting billions of AIDS dollars on "schoolgirls and housewives and Boy Scouts" when they should be concentrating on preventive measures for the people who are actually at risk for this deadly disease: "junkies and gay guys and the people who buy and sell sex."

If you are someone who believes that "junkies and gay guys and the people who buy and sell sex" are getting what they deserve, this author has a message for you, too: remember who is infecting the housewives, Boy Scouts, and even the unborn children. The HIV-positive carrier could be your boyfriend, your sister, or your grandchild. Is there anyone in this 21st century without a friend or relative who is infected with this deadly retrovirus?

Some people may object to the frank language of `Whores.' Others may object to its message that condoms will do more to limit the spread of AIDS than misguided attempts at abolishing the sex trade. Most of us will have our eyes opened on what really needs to be done with our tax dollars in order to mitigate the worldwide AIDS crisis.

Review copy supplied by author

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 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 who 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. But don't think the liberal crowd, the NGOs or activists are off the hook either.

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.

Dr. Pisani is a rarity in that she is a scientist who can write! She is a former journalist turned epidemiologist (aka "epi")working in AIDs research amd prevention. Her book will interest not just those readers concerned with AIDs, but anyone who wants to understand the effect politicians and bureaucrats and competing NGOs(Non-government orgaizaions) have on public health. Often only scientists and academics can grasp the process and explanation of scientific research. Dr. Pisani explains it so clearly that the general reader will understand as well. However, she hasn't "dumbed down' the scientific research process and data analysis. Through out this excellent book she shows a deep respect for the intelligence of her reader. No matter what opinion someone has regarding AIDs and its victims, this book will help improve understanding of the disease, its transmissions, the risks of being infected, and how its spread could be stopped. The title may be shocking, but sometimes it take a shock to get many of us to pay attention. Buy this book! Once you start reading you will not put it down until you reach the final page!

It's difficult to offer a contrary view in the face of so much enthusiasm, but I feel like it's important to add something different to the discussion of this book. I should mention that Pisani and I are rough contemporaries with overlapping time in Asia. I don't think we've ever met, although Pisani and I have known and even worked with some of the same people and they generally come across in a way that is recognizable to me. I came to the book via reviews on [...] and elsewhere. The book starts off in a promising way, mixing the personal and the professional and avoiding the dreaded "too much information." As the book continues, it becomes more polemical and despite an effort at structure, it begins to lapse into stream of consciousness, with important issues quickly raised, but with little follow-up and complex issues treated with oversimplification, as in the cases of sex work and poverty. The scholarship is spotty in places (e.g., recent history of sexual mores in Thailand, which had been changing for women even before the HIV epidemic). The scholarship also falls apart in small ways. For example, Pisani places her former employer's HQ in Washington, DC when, in fact, the DC area presence has been shrinking and the HQ always has been in North Carolina. I'd been hoping to get more wisdom of whores, but ultimately, it's too much of Pisani and her own melting down.

The book is puzzling in places. Pisani complains about numbers and the difficulties of measuring HIV cases and risky behavior, but never really enlightens the reader about why this is important and how people treat soft data. Given her training in demography and epidemiology, she should have been able to do this better than someone who has learned epidemiology on the ground like me. Pisani does things like raise the issue of non-injection drug use as a driver of HIV epidemics and then never comes back to it. The discussion of sex work rightly questions the motives and the evidence for some efforts directed at trafficking, but ultimately goes overboard in minimizing things like debt bondage and the growth of trafficking in some parts of SE Asia. There are similar problems with her treatment of economics. In many of the poorest parts of the world, there is relatively little HIV, but poverty often plays a role, as a driver into sex work and the drug trade and in terms of HIV's impact on working age populations (particularly in Africa). The tendency to over generalize and to play the role of iconoclast mars much of the book, particularly in the later chapters

Compared with literate researchers like Chris Beyrer or the rare journalist knowledgeable about HIV like Jon Cohen or Randy Shilts, Pisani comes off poorly. As a polemicist, her use of evidence is too easily challenged by someone working in the field. In addition, she fails to communicate the difficulties in predicting where the epidemic will go, how much it will expand, and where it might be contained. The magnitude of the Thai epidemic of the 1990s surprised many people, as did the more recent epidemic among gay men in Thailand. The epidemic has been contained in unlikely places that have unstable or poor infrastructures, while continuing to devastate in places with relatively functional public health systems. Pisani spent her time in residence in Indonesia, a country with many ingredients for a concentrated epidemic of significant size and yet, it's unclear from the book or from other evidence, why Indonesia has not experienced the rapid expansion seen in Vietnam or the kind of general population epidemic that occurred in Thailand during the early 1990s. While Pisani provides some discussion of why HIV Africa is different from Asia, she never really explains why it varies so much on both continents and her description of Africans having more sex actually flies in the face of a lot of data. Explaining the situation in Indonesia, particularly in comparison to Thailand, Vietnam or the Philippines (another country with "ingredients", but a limited epidemic) would have added greatly to the value of the book.

In the end, it becomes apparent that Pisani became burned out and given the tone of the later chapters, it's neither unsurprising nor something that should be viewed unsympathetically. The later chapters raise issues and concerns but offer no solutions. I would guess that the solution for Pisani was to write a cathartic book and move into consulting work. I wish her well, but I really have trouble recommending that anyone read the book.

For sheer accuracy of synopsis, maybe "The Wisdom of Whores"'s subtitle ought to be "Practical Epidemiology, What We Know About Solving the AIDS Crisis, and How the Politics of International Aid Complicate Matters." Though Pisani probably wants to sell a copy or two.

This is one of the few books I've read that actually lives up to its jacket blurbs. One author describes it as not only a work of science, but also a page-turner. And indeed it is. Pisani holds a Ph.D. in epidemiology, and you can tell from reading The Wisdom of Whores that she has the chops to do serious data analysis. It's data analysis in the service of a practical end, namely figuring out the most efficient ways to stop AIDS. Pisani has been on the ground interviewing prostitutes and junkies for a couple decades now, so she's learned a bit about how the disease actually spreads.

Part of the answer is just common sense: HIV spreads when an infected person's blood comes in contact with an uninfected person's blood. When heroin users share needles, the risk of HIV's spreading rises. Unprotected sex is riskier than protected sex. Unlubricated sex is riskier than lubricated sex, because the risk of causing tears is higher. Uncircumcised men are at higher risk than circumcised men. Prostitutes and their johns are at higher risk than non-prostitutes, because they have more partners.

This much should be common sense; the fact that this common sense often doesn't translate into policy is where the "bureaucrats" in the subtitle come in. The Bush administration and many other nations have changed the conversation: we don't talk about the actual mechanics of sex and drug use, in part because prostitutes and drug users are considered wicked, and it helps no politicians to aid the wicked. From a public-health perspective, most of our effort ought to be focused on the populations that are most at risk: addicts, gay people, and prostitutes. But that doesn't sell. What sells is to talk about "neutral" topics: pretend that consumers of prostitution come home to their innocent wives and unwittingly give them the disease, which then spreads to their kids. When you frame the issue as "AIDS hits everyone," surely you can get votes. Likewise with international aid: if you tell your voters that "poverty and gender disparities" cause AIDS, you can sidestep the icky topics of sex and heroin injection.

Once the money flows, there's a great risk of corruption and waste. Fortunately, Pisani tells us, there are a lot of people on the receiving end of that money who are really trying to do right by the world's taxpayers. And there are organizations like the Bill and Melinda Gates Foundation that seem to disburse funds more efficiently and measure programs' effectiveness better than a lot of governments do. And the governments are learning from their mistakes, in no small part because the epidemiologists on the ground are pushing back on them. Pisani never takes the step that a lot of libertarian fanatics do, namely jumping from the observation that foreign aid can be wasteful to the conclusion that all foreign aid should end. That's because Pisani isn't a libertarian fanatic. She's a hardworking, nose-in-the-details scientist who, like a good disciple of Herb Simon, tries to assume as little as she can before she starts gathering data.

Indeed, the big takeaway from The Wisdom of Whores is that reality is complicated, and that the only way to actually help solve the AIDS epidemic is to dig into the details and be honest about how the disease actually spreads. Don't let ideology, for instance, blind you to the virtues of free condom distribution. Don't let ideology stop needle-exchange programs. At the same time, don't let ideology convince you that needle-exchange programs always work: look at the data first. This book is what happens when a truly scientific worldview merges with the passion of an activist.

I am seldom found without at least one book close at hand, and end up trying to give books away in order to keep my shelves from collapsing. But I'm not ready to give this one away, I intend to read it again in a while. What I might do, however, is to order a few extra copies and have them delivered to people I know. Why just this one? Because it is one of those books that you come across once in a while, that works on more than one level. It is a book that keeps me turning the pages, with the energy that comes from a genuinely engaging story. Then there is the author's solid knowledge of the topic, and her ability to present it in an accessible way. This is a writer who knows her tools: she knows how to structure a presentation and how to juggle angles to keep it interesting, all in a style that gets the message across clearly and simply, with a strong personality and sense of humor. But the main reason why I want to gently blackmail my friends into reading it by buying it for them, is the information it contains and the message that it spells out. It is an important book. It untangles the facts about HIV and HIV prevention from the myths, which is good. It also shows clearly how ideological/religious/political/economical agendas often play a bigger role than science, which is depressing ... but essential to know. Getting the facts straight, about the infection and about the HIV/AIDS industry, is vital. And in my mind, Elizabeth Pisani is exactly who you should turn to for those facts

This stunning book describes the fight of medical professionals to fight global AIDS. Elizabeth Pisani's job was to collect data on sexual practices in Malaysia, Thailand, China and Africa for various UN agencies. Her book details the difficulty of gathering honest data. It also tells of the cultural assumptions that make data collection inaccurate and hence useless for saving lives. For instance, data collectors in Asia ran into combinations of drug users and sex workers that don't fit neatly onto their neat data sheets. A "waria" (a man who dresses and self-identifies as a woman) can service multiple men; her "husband" may do drugs and visit female prostitutes, who themselves have husbands. The myriad combinations of sex partners and drug use make it difficult to estimate the extent of HIV infection and to propose effective remedies for containing the spread of the disease. In Africa, Pisani describes casual cultural attitudes about sex outside marriage that are nearly impossible to abolish. Western religious groups come in for a drubbing for their naivete and "moral" opposition to life-saving practices like wearing condoms. Even US foreign aid is suspect, being restricted to spending money on US products, like condoms, which cost a tenth as much if purchased locally.

"The Wisdom of Whores" is a gritty, eye-opening look into actual sexual practices around the world, and their consequences for the spread of AIDS, this most dangerous of diseases. The book is also a look at the need or activists to sell reluctant governments, sometimes using cooked up data, on doing what is right or their citizens. Pisani is also not afraid to rock the boat when science is on her side. Her surprising, but well-grounded, argument that AIDS is actually very difficult to catch, goes against the popular thought that it spreads easily. But (to try to be delicate) it requires unlubricated, tissue-tearing sexual activity at a time when the infected partner is newly-loaded with the virus. This reality suggests ways to reduce the likelihood of infection that make people uncomfortable, and hence les willing to talk about it and save lives.

"The Wisdom of Whores" is a fact-filled, often funny and deeply affecting book on a great plague, and the difficulty of getting human beings and their governments and religions to do anything effective against it.

"The Wisdom of Whores: Bureaucrats, Brothels and the Business of AIDS," is a remarkable new book by London-based Elizabeth Pisani. The author, who is an epidemiologist, specializes in HIV surveillance and protection, and has provided research, analysis and policy advice for UNAIDS, the World Health Organization (WHO), the World Bank, governments on four continents, and other organizations. Pisani began her work life as an Asia-based journalist; and she brings considerable knowledge of Asia, an impassioned commitment to the eradication of AIDS, and a journalist's clear, informal writing to the book at hand. It makes for quite a package.

The author formerly wrote for Reuters, and "The Economist;" she is evidently a hands-on sort of gal, who's been out and about, principally in Asia, spending 14 years trying to figure out how AIDS spreads, and how to stop it. She's met a great many bureaucrats in her efforts; also a great many whores, and quite a few brothel-keepers, too; her reports back from the front line are fascinatingly factual: despite the ultimate seriousness of her subject, they are entertainingly written, to boot. I wouldn't have thought it possible.

She reaches a few surprisingly controversial, at this late date, conclusions: condoms used in sexual intercourse, and clean needles for injecting drug addicts, save lives. She argues against waste, foolishness, and fraud in the effort to beat the disease. She further argues that the way the Western world first became familiar with the disease, largely among the homosexual community, set disease circles and clichés of treatment that do not necessarily apply to society as a whole. Finally, she argues, convincingly to me, at least, that the horrendous swathe AIDS has taken through Africa, laying waste to whole towns and orphaning innumerable children, will not be the way AIDS will spread in other countries. This African pattern has been used to scare the world into greater AIDS awareness, and into donating greater sums of money to fight the epidemic, all to the good, she says; nevertheless, she argues, overwhelming political correctness has prevented the AIDS community from acknowledging that the patterns of sexual activity seen in Africa are simply different from those she sees elsewhere.

Well,who'd a thunk it? An entertaining, seriously educational, accessible, easy-to read book about AIDS, written by a qualified scientist, no less.

I read a lot, on a wide variety of topics. If it has words on it, I'll try to read it, even if I _don't_ know the language, I'll try to decipher it. But some books are much more rewarding than others, and this is one of the most rewarding books I've ever read.

The other reviews cover the topic well: she's a great writer, a person who really cares about people and not just people who are like her, a scientist who can understand numbers and make them make sense to others. She has a wide-reaching understanding of how AIDS is transmitted, and how that transmission is partly biologically determined and partly culturally determined. And she can convey that complex and detailed understanding in a simple way. Repeatedly, so if you miss it the first time, you get a lot of additional chances. And with hilariously shocking illustrative stories, so there's no remote chance of boredom ever setting in.

I know there's no way she's going to slog through bureaucracy for a second cause -- that would be unfair to ask of anyone. But I hope global warming/climate change/peak oil/etc. gets someone half as brilliant as Pisani. Hopefully several someones.

I had never read a piece of social research before that was truly a page-turner -- until I read Elizabeth Pisani's wonderful book. This book is not only eminently readable -- for academics and lay readers alike -- but it is also organized and assembled in an intricate fashion that weaves ethnographic accounts of the street realities of HIV transmission among the most vulnerable populations of the developing world, along with the day-to-day efforts of Pisani and her epidemiologist collaborators' efforts to find and study these vulnerable populations, and still manages to lay out logical arguments about HIV transmission and the sanctimonious efforts of U.S. AIDS policy under the Bush (44) Administration. In fact, the flow of the book is so good that readers could almost lose sight of the practical reality that Pisani and her editors actually consciously worked at organizing this text.

I imagine that some in the halls of epidemiological science will take offense at Pisani's graphic street-level depictions and language, and perhaps even the title itself. Those who do will be the poorer for their arrogance. As an academic who teaches field research, I can say candidly that I was inspired by Pisani's depictions, her explanations, and the analytic processes that lie close beneath the surface of what she portrays in her writing. Her critique of the epidemiological research that accounts for HIV by poverty, gendered power relations, and barriers to development rang a coherent bell. She ably demonstrates in graphic depiction the everyday mechanisms by which HIV is transmitted -- unprotected sex and sharing needles among drug users -- even though epidemiologists' models of distant "causes" help to sustain Western do-gooders' attention to the problem. Her work is an inspiration to those of us who believe the nature of the social world is found, not in clean models of "predictor variables," but by getting your hands dirty by finding out how things happen on the street.

Some may be offended by Pisani's title, but it quite accurately captures the spirit of the book. Pisani's message is that if you want to understand AIDS in the developing world, you need to ask those who know most about its transmission: sex workers and drug addicts. Pisani's book succeeds because her research doesn't shy away from the the Third World back alley people with true wisdom about its transmission.