Billions of dollars have been spent on the fight against the HIV epidemic over the past decades. Yet, the grim fact is that these expenditures by development agencies failed.
Part of the problem lies in the UN cookbook – the blueprint of fighting against HIV/AIDS, which bears little correspondence to the local context, argues Elizabeth Pisani – an epidemiological researcher, in her book, The Wisdom of Whores: Bureaucrats, Brothels and the Business of AIDS. The manual or the HIV mantra – ‘information, education and communication’, believes that raising awareness of how AIDS is spread, educating people, and telling them how to avoid it is the key. But, what works in Afghanistan might not work in Zimbabwe.
Written over a decade ago, the book illuminates the underworld of junkies, pimps, prostitutes, transvestites (called ‘Waria’ in the Indonesian language), dealers and users. The not-so-good news is that there has been little change since then.
To obtain an accurate picture of HIV’s prevalence, Pisani started collecting data, including mapping, defining boundaries, surveying, and getting the right people to ask the right questions. Pisani found that some men, who consider themselves straight, exchange money for sex with other men, that prostitutes never use condoms with their boyfriends, that junkies also buy sex and have girlfriends who are sex workers, and that many waria have husbands.
What causes the spread of HIV?
While acknowledging that social and economic circumstances sometimes rob people of decision making power, Pisani is not content with the premise that poverty and gender inequality spreads AIDS. She argues that it is sex and drug use that spreads it. To defend her position, she provides much evidence. For example, Bangladesh has rampant poverty and gender inequality but a low rate of HIV, whereas South Africa and Botswana, with the highest female literacy rate and per capita income in Africa, have the highest HIV infection rates.
Most importantly, some challenges stand in the way of the global response to AIDS, such as too much focus on treatment programs, religious dogma, the war on drugs, and development initiatives.
To contain HIV, countries prioritize treatment instead of prevention programs. People, with access to the treatment, are less intimidated by HIV. They then toss the condom aside. Hence, the governments have missed the target as the HIV infection rate continues to rise.
It is perhaps not surprising that religious dogma has played a crucial role in hampering the global response to HIV. One example is US President George W. Bush’s $15 billion ‘President’s Emergency Plans for AIDS Relief’ (PEPFAR). Christian lobby groups insisted on the inefficacious abstinence programmes, which contend that more premarital sex will increase HIV infections. These abstinence programs have failed both at home and abroad.
Digging deeper, Pisani contends that the war on drugs also exacerbates the problem of injected substances in many countries. Such is the case of Thailand, where one in six users had their first injection in prison. The stats in Russia, Canada and several western countries are similar. Drugs are cheaply available in jail, so it is a place where people are introduced to this activity.
Subsequently, Pisani criticizes the development initiatives claiming that the fund is a disguised form of global capital, extracting profits instead of benefiting the infected people. Since the mid-1980s, USAID, for example, has purchased some nine billion condoms costing five cents each from Alabama and shipped them to Indonesia, India and China, while the cost is only two cents each in these countries.
She then goes on to explain the flawed model of NGOs. Perhaps not surprisingly, the sheer volume of available money tempts the NGOs to compete to grab a slice. A cited example is that Church World Service in Indonesia which teaches prostitutes to bake cakes, harrassed another local NGO that provides health services to sex workers in the same area. These NGOs claiming to help sex workers make it a business industry. After getting the money, they prove to the international community that they have spent according to the rules, but not that they have spent it well.
‘In the AIDS industry, we were all whores’, writes Pisani in the last chapter. To my understanding, whores, in this case, mean that people are willing to do anything to get what they want, and here, that is money. For example, Christian groups lobbied the US government to spend a third of PEPFAR funds on abstinence-until-marriage programs, which are in line with their moral obligations. Throughout the implementation process, NGOs work for this money, not for the sake of fighting against the HIV epidemic.
The book is very well-written and informative to any person who wishes to understand the HIV epidemic. Yet, it focuses too much on epidemiology knocking other things off the radar screen. Viewed through this lens, she has deliberately downplayed many socioeconomic inequalities as being minor. Although she raised the case of rampant poverty in Bangladesh as opposed to the rich countries like South Africa, one cannot deny that some women fall into prostitution because they need money, thereby exposing them to a high risk of HIV infection. The process feeds on itself.