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Tyee Books

'The Wisdom of Whores'

Author Elizabeth Pisani on AIDS treatment, drug abuse, and hard-headed compassion.

By Reanna Alder 17 Jul 2008 |

Reanna Alder is a Vancouver writer.

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Harm reductionist Elizabeth Pisani.
  • The Wisdom of Whores: Bureaucrats, Brothels, and the Business of AIDS
  • Elizabeth Pisani
  • Penguin (2008)

There's a little thrill to stumbling across one's own humble Canadian city in print, shoulder-to-shoulder with such bright lights as Jakarta, Nairobi and San Francisco. Hold the civic pride, though: the chapter is called "HIV Shoots Up," and author and epidemiologist Elizabeth Pisani is talking about AIDS among injecting drug users.

Pisani is writing about an ongoing argument with her father over needle exchanges. As you might guess from the title of the book, Pisani is a harm reductionist. Her father, a retired ad-exec and one-time member of the Partnership for a Drug Free America, "sends her e-mails that claim that needles are the devil's work."

For the most part, the so-called drug warriors make their claims without relying on evidence, or they read the data in imaginative ways. But here's where we come in: an oft-cited study from the mid-'90s actually found higher rates of HIV infection among needle exchange users (compared with non-exchange users) in Vancouver (this was before the Insite safe injection clinic was opened in 2003.)

What gives?

As Pisani notes in the book, these results shouldn't be surprising: it's those who are already at the highest risk of HIV infection that are most likely to use needle exchanges, not high-functioning addicts with homes and other sources for clean needles. On top of that, at the time of the study, the Vancouver needle exchange was rationing needles even as the drug of fashion switched from the relatively moderate heroin to binge-inducing cocaine.

Over coffee at Finch's, Pisani adds that the reason similar results haven't come to light in other cities is that most needle exchanges are under-monitored and under-reported. "It's a good thing that we've seen that, because it means they're being honest about their data," she says.

The central argument of The Wisdom of Whores is that ever-rising rates of HIV transmission are not caused by gender inequity, poverty or other development issues, but by unprotected sex -- particularly sex between men, commercial sex, and the kind of polyamorous sex common in parts of Africa -- and by shared needles. What Pisani calls the "AIDS mafia" has worked to de-emphasize these facts, in light of our general reluctance to do anything nice for "hookers, gay boys and junkies." Instead we get education programs for school children and across-the-board testing of pregnant women.

Until recently, Pisani says, Canada was actually a leader in effective HIV prevention, but, "With the Harper government, we're seeing a drift to less evidence-based public policy." However, Pisani doesn't necessarily think that politicians are steering the boat away from compassionate and effective prevention programs.

"Why is Stephen Harper doing what he's doing? He's a smart politician. Is he doing it really out of personal conviction? Or does he think there are more votes in not helping junkies than in helping junkies? Certainly in the United States that's what we're seeing. And it's not a North American phenomenon. [Thailand's] Thaksin Shinawatra went around and shot junkies, and everyone loved it, except the urban elite in Bangkok, who threw him out in a coup -- but the voters loved it."

Here's what else Elizabeth Pisani had to say:

On the difficulty getting mainstream media attention for the book in the U.S.:

"It's strange because in the States now there's the battle about the reorganization of $50 billion in AIDS spending. It's being held up by these Republican senators because they want to spend the money treating innocent women and babies, with the belief that treatment is prevention."

On the myth that treatment is prevention, and how we're helping AIDS to spread:

"AIDS is a very clever virus, inasmuch as it takes 10 years to begin to destroy your immune system, so it gives itself a really good long time. A dumb virus is Ebola, which is incredibly deadly and so it wipes out its host before it has time to propagate very much. HIV hangs around for a very long time. In fact, what we're understanding now is that a lot of the transmission happens very early on, when you have this peak viral load that happens right at the start.

"The question is, will HIV evolve to be less deadly over time, so that it will be able to survive longer? Well, that's what we do with treatment. Treatment also makes people less infectious, in as much as it lowers viral load. But here's the thing, and I have to draw a diagram..."

[Pisani draws a chart depicting viral load over the course of an infection]

"First you get infected. Your ability to transmit HIV is determined by how much free virus is in your body fluids, particularly in your genitals, but also in your blood. When you first get infected, the virus multiplies like mad [and your viral load shoots up], and then you start making antibodies and it brings it down to a set point. This takes only about two months, and then it goes brrrr [the viral load levels out at a low level]. Then you get another sexually transmitted infection [and your viral load blips], and then it starts getting the better of your immune system and [your viral load] starts to climb again.

"In most of the world they're starting treatment here, when AIDS is destroying your immune system. So instead of going to here [viral load skyrockets], it comes down again. We call this the Lazarus effect. But then maybe you get another STI [and your viral load blips], and then you have a treatment interruption [and it blips again], and then it can go on for -- we're not really sure how long.

"People who say that treatment is prevention are saying, "Because I've reduced your viral load here, I've made you less infectious, and therefore that's prevention.

[But] the question is, what happens to behavior [when AIDS "disappears" through treatment]? If condom use falls across the board, or multiple partnerships increase, you're going to have more spikes [in viral load] associated with STIs. Even when you're on treatment [an STI is] going to make you more infectious."

On our preference for the Mother Theresa approach, sin and retribution:

"Mother Theresa. She's a saint. Did she ever do anything to change the situation of people, to make it less likely that people were in need of rescuing? No. It's all over the Bible that you help people who are sick. But for some reason we do not translate that into it being compassionate to stop people from getting sick in the first place.

"It's sin, retribution, redemption. It's associated with this deep-seated Judeo-Christian morality, but we also see it in the Muslim tradition. We don't see it in Buddhist countries, for example -- they've been extremely pragmatic for the most part in their response to HIV -- and we don't see it in Confucian societies. It's the, 'We're good people, we help bad people, but only when we're helping them to redeem themselves' approach.

"I find it so difficult to understand why it's okay for me to give you a really expensive antiretroviral for the rest of your life, but it's not okay for me to give you a clean needle. I don't get that."

On sharing toothbrushes and sharing needles:

"No one wants to share a needle. There used to be this idea that, 'Oh, it's part of the injecting culture, it's a sign of solidarity and blah, blah, blah.' That's like saying you'd rather share a toothbrush with your boyfriend than have your own. It's icky. People don't want to share equipment that they put into orifices of their body! Or make orifices with, as it were. So it's actually the easiest area of HIV prevention. Condoms use is much more difficult because most of us would rather have sex without one than with one. But with needles, if they're available and easy to use, and you're not going to get arrested for carrying one, mostly people will use their own."

On the myth of evidence-based decision making:

"I'm coming to the view that you can't ever trump ideology with science. I was doing a presentation at USAID called 'Time to Slaughter Some Sacred Cows.' I was making slides of all the sacred cows, grouped by: here are the activist sacred cows, here are the religious right sacred cows, and then at the end I thought, God, you know, I didn't have the public health sacred cows. The number one [public health sacred cow] is that we keep talking about evidence-based decision making. But if there's one trope of our profession that is not evidence based, it's the idea that governments react to data. I mean shit, if there's one thing for which there is no evidence, it's the idea that if you do better research you'll get a better policy."

On denial:

"The biggest mystery for me is South Africa. You've got one in five adults infected with this disease, and still there's a level of total denial throughout society. No one is getting rid of [President] Mbeki because he's denying the progression of an epidemic, a fatal disease that is affecting a fifth of the population.

"You've got the Treatment Action Campaign jumping up and down asking for meds for the people who are already infected, but there's no call for prevention -- none -- in a country where one in five adults is infected. Imagine if one in five adults in Canada were infected with avian flu, let's say, but a slower version. It starts to infect people and we track it and measure it and we do nothing about it, until one in five people are infected, until your risk, if you're a 15-year-old, of getting it at some time in your life is over 66 per cent.

"Wouldn't the voters say something about that? Wouldn't they say, 'We know how to prevent this! We want prevention, we want services'? If it's [preying on] the general population and you still can't sway the voters? You expect politicians to be plonkers, but what about us?"

On AIDS and global warming:

"I did a radio interview with CBC. They wanted to talk about how rising food prices are going to increase HIV. I was like, 'Uh-huh, talk me through that one.' She said, 'Oh, well, of course, rising food prices are going to increase the number of women selling sex.'

"Spot the problem with that. What about disposable income for buying sex? It takes two to have a commercial transaction. People automatically think if the economy is going to shit, there will be more people selling sex. No, there has to be more people buying sex. We have very good data from Indonesia, from 1997 during the financial crisis in Asia. The proportion of guys buying sex just went whoomp.

"The same thing is happening now in Zimbabwe, which the WHO and UNAIDS have the gall to point to as a prevention success story. You think the Mugabe government is doing great things for HIV prevention? First of all, a lot of people at the highest risk have fled the country; and number two, no one can afford to go out and get drunk anymore, or pick up girls. So we measure a huge reduction in the number of casual partnerships, and 'outside wives,' as they call them, 'little wives.' Not because of any prevention measures, but because the economy's gone to shit."

On using drugs for fun:

The Tyee: "You take what some might consider a fairly light-hearted approach to drug use. You talk about people using because it's 'fun,' rather than because they're hurting."

EP: "Have you ever taken drugs?"

The Tyee: "Yes."

EP: "How emotionally disturbed are you? You seem pretty well adjusted. Why'd you do it? These things are circular. You could start something because it's fun, or because you're shy, or because it makes you feel like part of the crowd. There are all kinds of reasons. Automatically assuming that groups of people are vulnerable and abused is just a cop out. Addiction is certainly one way of escaping from a life that sucks, but your life can start to suck because you've become an addict. Alcohol is the drug where we see that most of all -- do you start drinking because you're depressed? Maybe you go through a bad phase, your boyfriend dumps you or whatever, you start knocking back a bit and then suddenly it's an addiction, and then your life really starts to go south."

On the power of a good title:

"The book was in a way a last gasp. By packaging it differently and saying it to a different audience, it was a last attempt to see if it made any difference. I've worked for the World Bank, I've written my reports and I've given my input on strategy, but no one paid a blind bit of notice, and then you package it in this format, in a book, and you give a brown bag lunch at the [World] Bank and 50 people show up, including the head of programming, and suddenly people are listening to what you're saying. Just because, what, because you thought of a good title?

'The Biggest Story in the World' I'm not saying anything new. I've been saying it for years. And it's not just about me, there's lot of people inside the industry who've been saying it. But why is nothing changing? That's my question to [UNAIDS executive director] Peter Piot. No one has said, 'This is not true.' No one has objected to a single fact."

On what she might have done differently:

"Given some of the reactions to the book, I think that maybe I'm banging the drum too loudly against all these [education programs aimed at the] general population. The truth is that doesn't do any harm, it just doesn't prevent any HIV infection. But if that allows you to get on with the stuff that you need to do for hookers, gay boys and junkies, then it's a good thing. If it creates a level of public awareness, then that's fine. The problem comes when you do that stuff instead of real prevention."

Visit Elizabeth Pisani's blog,, for more.