'We pretend it's not about the type of sex'
A new book explores how the Aids prevention industry masks the real stories of the victims, writes Donal Lynch
Elizabeth Pisani seems an unlikely Aids expert. Relaxed and nattily attired, with stray curls shading her eyes from the afternoon sun, she looks more like Juliette Binoche with a movie to promote than an epidemiologist with some harsh home truths. I can't imagine her wearing latex gloves.
And yet, benign appearances aside, Pisani packs quite a punch. Her book, The Wisdom of Whores, ignited a mini-firestorm of controversy and had one critic wondering whether her former colleagues at the UN wouldn't be wishing she could be somehow thrown over a bridge. It exploded several prevalent myths about the diseases, including the lie that poverty and Aids are inextricably linked, and called into question the whole morality of how Aids prevention campaigns are conducted. Written in an accessible style, often with the same black humour that Pisani displays in person, it scythes through the piety and political correctness of what has become a billion Euro industry.
"I was rather anticipating that there would be a reaction," she tells me. "In this institutional world of Aids prevention, where the big money is, there were eyebrows being raised. But I was encouraged because we had a bit of a bash to launch the book and there were people there from the Terrence Higgins Trust (a British charity that campaigns on HIV-related issues). They were really supportive and told me that there are a lot of people on the inside thinking these things but not saying them". Pisani had a peripatetic childhood, growing up "mostly in Western Europe" while her American-born father moved the family around. She did her PhD in infectious diseases in London and then spent "much of my adult life" working in Asia, at the coal face of Aids-prevention. The central thesis of her book is that the down-to-earth common sense of the prostitutes and clinicians who deal with the disease on a daily basis is somehow lost in the political correctness of the multi-million dollar prevention campaigns.
Her take on the issue of guilt and innocence and how Aids victims are viewed is fascinating, and she points out that the images used in campaigns are generally of African orphans, not the young gay guy who decided to have risky sex. "But why does it apply only to HIV?" she adds. "Why doesn't it apply to diabetes or cancer? We don't tell people it's their own fault for getting those diseases -- when it often is -- but HIV has maintained this stigma. And the stigma itself has got in the way of doing the right thing by the people at risk. Because we're so wary of stigmatising certain groups that we don't properly target the groups at risk and we pretend it's not about sex and the type of sex."
As the Nineties progressed, mainstream society was continually told that HIV was "not just a gay disease and was coming for you too," she tells me. But this hasn't turned out to be the case. "People were so concerned with gay men being discriminated against that they actually did those same men a disservice. The fact is that they are more at risk and they need to know that."
She also calls into question the received wisdom that Aids has much to do with poverty or that this is why it's such a big problem in Africa. "Look, the fact is that they have more sexual partners and more risky sex in Africa. I've had people attack me for saying this, saying, 'You can't say that, it's racist'." But why is it a racist thing to say that people have more sex? It doesn't matter at all until it becomes dangerous to them and others." She gives examples: "Why don't we have HIV in Bangladesh? Why don't we have it in Niger, in central Africa? Why don't we have it in Afghanistan? Whereas you have somewhere like Botswana, one of the richest countries in Africa, which has really high rates. I don't buy the whole 'people have sex because they're poor' thesis, and the evidence doesn't support it."
The hypocrisy of the prevention campaigns filters down from the hypocrisy of the wider societies they target. "The reasons are complex and go back to the places of women and men in society. Every religious group is anti-sex in one way or another and that leads to a lot of hypocrisy about sex and the types of sex people have. Even in societies that aren't so religious any more these attitudes have been passed down and remain." Her hope that sex can be viewed more dispassionately, as a risky activity along the lines of eating fatty foods or driving without a seatbelt seems somewhat ambitious, and she acknowledges this with a weary shrug. "I have to be realistic. People are never going to leave morality out of sex. My point is that human beings do stupid things; they especially do stupid things where hormones and erections are involved. When the stakes are as high as they are with HIV we need to be slightly more objective."
She sees some progress on this front, however. "What's been interesting to me is seeing the transformation of the American right from demonising people who had it (HIV/Aids) to pushing for proper treatment for sufferers and prevention campaigns. That shows there's some hope." She speaks as someone who has had experience with the disease not just as a professional but also on a personal level. "A friend of mine -- just 20 years old -- told me recently that he had become infected. I wanted to slap him around. I just felt, 'How could you be so stupid?' He's well educated, knows everything about everything. I'm not judging him as a human being, I'm judging his poor risk assessment."
It might sound harsh in print but she says it all with a kind of loving regret and holds up her hands to her own mistakes. Hers is a kind of tough love that has been out of fashion in HIV prevention for a long time but, with rates for the illness steadily climbing, including in Ireland, Pisani's pragmatism may yet come to inform Aids prevention.
'The Wisdom of Whores: Bureaucrats, Brothels and the Business of AIDS' by Elizabeth Pisani, Granta Books, £12.99
- Donal Lynch
