The Wisdom of Whores: Bureaucrats, Brothels, and the Business of AIDS by Elizabeth Pisani. W. W. Norton & Company, 2009.
At its heart, this book is about the waste of funds, time and human life that inevitably results from the subordination of science and evidence under politics and ideology in the creation of policy. Pisani reviews the facts of the HIV/AIDS epidemic including who is most likely to be affected, why and discusses which of these facts can be discomfiting to both puritanical and politically correct world views. She explains the high risks for HIV infection faced by prostitutes, intravenous drug users, and people who have multiple sexual partners who in turn have many partners (creating a kind of sexual web network in which HIV can spread more effectively than multiple partners encountered via serial monogamy). Despite these high risk groups being the most logical targets of interventions from a perspective of efficiency (and clearly those in greatest need), they do not always make good "poster children". What’s interesting in this story is that by overplaying the risk to other more "sympathetic” groups to increase the willingness of, for example, the US government to invest in assistance, and accepting the ridiculous strings attached to that assistance, NGOs and activist groups may have indirectly validated the judgemental attitudes and hypocritical moralizing that would seek to deny assistance to people seen as “icky” or unsympathetic. There are profound questions for scientists and epidemiologists here. Can we non-judgementally identify some groups (including those who have experienced extensive oppression or neglect) as being at extremely high risk of HIV if those risks are attributable to behaviours that are typically subject to harsh moralizing judgement? Do scientists have an obligation only to the truth or to how the truth may be used, however unjustly or illogically, to deny assistance to those in need? My take on this (and I think Pisani’s too) is that we must start with the truth. If we don’t stick to the evidence and argue for its logical application, who will? There’s also a call here to be realistic about how humans work. It doesn’t really matter how "wrong” or “stupid” we think intravenous drug use is, the reality is that addicts are going to use if the opportunity is there. Humans are going to have sex, no matter how good of an idea or how morally right they or you might think abstinence is. If your policy ignores these realities, it’s just not going to work.
Pisani also expresses her skepticism of the "treatment as prevention" model (in which antiretroviral treatments that lower viral load are assumed to also make people less infectious and therefore prevent transmission). Her argument is based on the natural history of HIV infection. Untreated, viral loads are very high quite early on, but are eventually somewhat contained by the natural immune response. They then spike very high again when that immune response fails, precipitating full-blown AIDS. Pisani argues that treatment can't really address that first spike, because most people don't even know they are infected at that point, and that by the time full-blown AIDS manifests, people don't feel like engaging in transmission activities or are not attractive partners. However, since the book's publication, additional empirical scientific articles have emerged suggesting that treatment may also provide effective prevention. I wonder what Pisani would say about treatment as prevention today.
One thing I found a bit off-putting (a minor thing) was Pisani’s extensive use of slang to describe various groups or practices. I think she uses this language because she’s an on-the-ground type of researcher: when she does her research she has to use the terms her population of study will recognize. Maybe it’s my own puritanism or political correctness that made me uncomfortable. I guess I see some of these terms as being either value-laden or not appropriately descriptive or operationalized (e.g. the difference between the terms “gay” and “MSM” is that one is behaviourally descriptive rather that a subjective concept that individuals may interpret differently).
There is lots of great epidemiology in this book, elegantly elucidated, and readers will come away with a fresh understanding of theory and concepts in action. While I’ve steered away from infectious disease epidemiology in my own work, this is probably one of my favourite books about epidemiology.
At its heart, this book is about the waste of funds, time and human life that inevitably results from the subordination of science and evidence under politics and ideology in the creation of policy. Pisani reviews the facts of the HIV/AIDS epidemic including who is most likely to be affected, why and discusses which of these facts can be discomfiting to both puritanical and politically correct world views. She explains the high risks for HIV infection faced by prostitutes, intravenous drug users, and people who have multiple sexual partners who in turn have many partners (creating a kind of sexual web network in which HIV can spread more effectively than multiple partners encountered via serial monogamy). Despite these high risk groups being the most logical targets of interventions from a perspective of efficiency (and clearly those in greatest need), they do not always make good "poster children". What’s interesting in this story is that by overplaying the risk to other more "sympathetic” groups to increase the willingness of, for example, the US government to invest in assistance, and accepting the ridiculous strings attached to that assistance, NGOs and activist groups may have indirectly validated the judgemental attitudes and hypocritical moralizing that would seek to deny assistance to people seen as “icky” or unsympathetic. There are profound questions for scientists and epidemiologists here. Can we non-judgementally identify some groups (including those who have experienced extensive oppression or neglect) as being at extremely high risk of HIV if those risks are attributable to behaviours that are typically subject to harsh moralizing judgement? Do scientists have an obligation only to the truth or to how the truth may be used, however unjustly or illogically, to deny assistance to those in need? My take on this (and I think Pisani’s too) is that we must start with the truth. If we don’t stick to the evidence and argue for its logical application, who will? There’s also a call here to be realistic about how humans work. It doesn’t really matter how "wrong” or “stupid” we think intravenous drug use is, the reality is that addicts are going to use if the opportunity is there. Humans are going to have sex, no matter how good of an idea or how morally right they or you might think abstinence is. If your policy ignores these realities, it’s just not going to work.
Pisani also expresses her skepticism of the "treatment as prevention" model (in which antiretroviral treatments that lower viral load are assumed to also make people less infectious and therefore prevent transmission). Her argument is based on the natural history of HIV infection. Untreated, viral loads are very high quite early on, but are eventually somewhat contained by the natural immune response. They then spike very high again when that immune response fails, precipitating full-blown AIDS. Pisani argues that treatment can't really address that first spike, because most people don't even know they are infected at that point, and that by the time full-blown AIDS manifests, people don't feel like engaging in transmission activities or are not attractive partners. However, since the book's publication, additional empirical scientific articles have emerged suggesting that treatment may also provide effective prevention. I wonder what Pisani would say about treatment as prevention today.
One thing I found a bit off-putting (a minor thing) was Pisani’s extensive use of slang to describe various groups or practices. I think she uses this language because she’s an on-the-ground type of researcher: when she does her research she has to use the terms her population of study will recognize. Maybe it’s my own puritanism or political correctness that made me uncomfortable. I guess I see some of these terms as being either value-laden or not appropriately descriptive or operationalized (e.g. the difference between the terms “gay” and “MSM” is that one is behaviourally descriptive rather that a subjective concept that individuals may interpret differently).
There is lots of great epidemiology in this book, elegantly elucidated, and readers will come away with a fresh understanding of theory and concepts in action. While I’ve steered away from infectious disease epidemiology in my own work, this is probably one of my favourite books about epidemiology.
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