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

by Elizabeth Pisani

A flame-throwing epidemiologist talks about sex, drugs, and the mistakes (dismal), ideologies (vicious), and hopes (realistic) of international AIDS prevention. When people ask Elizabeth Pisani what she does for a living, she says, "sex and drugs." As an epidemiologist researching AIDS, she's been involved with international efforts to halt the disease for fourteen years. With swashbuckling wit and fierce honesty, she dishes on herself and her colleagues as they try to prod reluctant governments to fund HIV prevention for the people who need it most―drug injectors, gay men, sex workers, and johns.Pisani chats with flamboyant Indonesian transsexuals about their boob jobs and watches Chinese streetwalkers turn away clients because their SUVs aren't nice enough. With verve and clarity, she shows the general reader how her profession really works; how easy it is to draw wrong conclusions from "objective" data; and, shockingly, how much money is spent so very badly. "Exhibit A": the 45 billion taxpayer dollars the Bush administration is committing to international AIDS programs. 12 illustrations

Genres: Nonfiction, Science, Politics, Medicine, Health, Feminism, History

400 pages, Hardcover

First published January 1, 2008

Reviews

[Elizabeth · Rating 5 out of 5]

I wrote this book so of course I think it's fantastic. But if you want more objective opinions, you will find all reviews so far (good and bad) at http://www/the-wisdom.com/reviews

[James · Rating 1 out of 5]

What a difference a title makes!!!


Sexual Ecology: AIDS and the Destiny of Gay Men by Gabriel Rotello

Is a far more interesting and informative book, but with a dull title it only has 8 ratings and 2 reviews.
Compare to the 288 ratings for this book!

I don't know what the title is suppose to mean,
there's no "wisdom" from the whores that are interviewed.

I guess it would make sense if the author considers herself a whore,
but I doubt that's the case.

Over 300 tedious pages,
about 49% of the time the author is preaching.

Another 49% she has this weary attitude that everyone else is stupid,
and if Seven Billion people would just do things HER way,
all would be right in the world.

I was surprised to learn, according to the author, that the average whore in
the Philippines only has 2 customers a week.

And that the wives in Africa fool around as much as their husbands.
When you think about it it kinda has to be that way doesn't it?

How can a bunch of men cheat if there aren't an equal number of women doing the same thing?

hmmmmm, that's not even 2%, maybe I should adjust the 49% numbers.


No glossary, and a poor index.

She explains what a "rent boy" is early in the book,
better remember, because it isn't explained again and the index won't help you.

I put it on the Health shelf, I think maybe I need a "Books I wish I never started" shelf.

[Elevate Difference · Rating 4 out of 5]

The arrival in 1994 of HIV and AIDS to the London School of Hygiene's curriculum led Elizabeth Pisani, a former journalist and scholar of classical Chinese, to contemplate "a career in sex and drugs." The Wisdom of Whores recounts her work for (and increasingly against) the funding and technical juggernauts of UNAIDS, Family Health International (FHI), the World Bank, the WHO, and the President's Emergency Plan For AIDS Relief (PEPFAR) in defining and surveilling upon HIV and AIDS. Pisani collects data in fetid settlements, brothels, sex clubs and hairdressing salons from the body parts and fluids of marginalized people and then massages the data ("beating them up" in journo speak) to placate politicians and sponsors.

Even chapter titles such as "The Honesty Box," "Sacred Cows," and "Ants in the Sugar-Bowl" critique the "big business" of AIDS managed by "the AIDS mafia." Skewering the absurdities of the "abstinence-only" movement and the opponents of "harm reduction" in matters sexual and drug-injecting, Pisani pits the "truth" of painstakingly gathered empirical data (doing "good" science in HIV and AIDS work) against the "right answers" that keep politicians elected and funding streams flowing. Here is her solution: "We could save more lives with good science, if we spent less time worrying about publishing the perfect paper and more time lobbying, more time schmoozing the press, more time speaking in the language that voters and politicians understand. If we behaved more like Big Tobacco, in fact."

The Wisdom of Whores reads (and was edited) breezily, but there is much to praise. Clinical and pharmaceutical specialists and development agency reps have had aired the dirty laundry of their infighting, money-grubbing and ill-conceived treatment programs. Lay readers will be titillated by her frank talk, have their eyes opened by her revelation of greed and corruption in national AIDS programs, and be liberated by her constant use of metaphor and colloquialisms. "Sex can be a sticky business. The stickier the better...A wet vagina is usually a pretty safe environment" conveys the frisson of having seemingly encountered dangerous words and ideas.

Nevertheless, the clarity of her take on needle exchange, data coding, epi-speak, and religious squeamishness about sex belies their nuances and complexities. She contends that "the circumcision and untreated STIs are easy to understand [in figuring varying HIV antibody prevalence:] and they are relatively easy to measure." Not so. Men are becoming circumcised instead of using condoms. The recently circumcised heighten their own infectiousness when they have sex still wounded. Women don’t benefit at the population level from circumcision. Men sometimes undergo supercision, superincision and even circumincision. None of this is easily measured.

Pisani discusses the politics behind use of acronyms such as MSM (Men who have Sex with Men), FSW (Female Sex Workers), and IDU (Injecting Drug Users) that stuffs into conceptual boxes for epidemiologists the identities and behaviors that won’t stay put. Her summary nicely spells out the difference between epidemiologists and ethnographers. Admitting that she and her colleagues "bulldozed happily through the minefield of language," she then castigates the very calls for nuance and caution in such matters that elsewhere she uses to dink mainstream epidemiology. Her confession that, "When we started to look, it didn’t take long to explode the 'junkies don’t get laid' myth," insults the legions of social scientists and activists who invented no such myth in the first place.

This is the blessing and curse of The Wisdom of Whores. Pisani complains (rightfully) about the language of mainstream epidemiology and its sacred cows, but her language is as imprecise as are her conclusions debatable. Her picking on the World Bank for believing “poverty and gender inequality spread AIDS” lets off the hook the sum total of the negative effects of the structural adjustment programs and unregulated capitalism supported by it and the IMF and WTO and ignores how hard social scientists worked to enable the World Bank even to put "poverty and gender equality" on the same table of HIV blame as cognitive shortfall and individual responsibility. Her claim that the fact that HIV antibody-positive men are eschewing condom use "wouldn't really matter if they were having sex with people who were also infected," is flatly untrue on several levels. She confuses "hot and dry" sex for "dry and tight," and ignores its "Western" manifestations. Indonesia’s waria (men who dress, identify and have sex as heterosexual women) do significant rhetorical duty here, but she fails to cite the important works of Jake Morin, Leslie Butt, and Gerdha Numbery, and ignores the lengthy genealogy in male-male sexual activity in the region. Her language often exoticizes ("Madurese women are famed for their sexual prowess") and is sometimes inflammatory: "If you have sex in ways that do not follow basic human sexual design (which includes a lubricated vagina), you will increase the chance of small tears and abrasions."

While rightly calling for ethnographic data and sensibilities that would explode myths, they were largely the making of Pisani and her colleagues. Rushing to appear marginalized as a consulting epidemiologist, she neglects how marginalized are most ethnographers by epidemiologists and the funding agencies and conservative philosophies underwriting them. The "big business" of AIDS begins properly with just such epidemiological conceits.

Review by Lawrence James Hammar, Ph.D.

[Lindsay · Rating 5 out of 5]

June 2016 re-read: I graduated from my MSc. in Epidemiology last week, so I thought I would re-read the book that started it all: The Wisdom of Whores. I first read this book back in 2010 and it literally changed my life. I was in the middle of a degree in International Development, and my main interest was in Global Health, with a particular emphasis on HIV. I was really unclear about what I wanted to do with my life and was increasingly dissatisfied with the largely ineffective development work we've been doing for the last century or so and the seemingly ambiguous marking schemes this degree involved. As I became increasingly jaded, I picked up this book. In it, Elizabeth Pisani mentions that she is an epidemiologist (the first time I'd ever heard that word) and on learning what the hell that was, I said, "That's what I've been looking for. That's what I want to do."

Cut to six years later, where I ultimately finished that undergraduate degree in 2012, started a graduate epidemiology program in 2013, and defended my Master's thesis (focusing on HIV testing) at the end of last year. I've also spent the last two years working in harm reduction research focusing on HIV and Hepatitis C. So, with all the ceremony surrounding convocation last week, I thought I'd revisit this book to really bookend the whole thing. Now that I've given this exceedingly long back-story, here are my highly anticipated thoughts on the re-read.

This book is still amazing. I'm glad to see I had good taste in books six years ago, and I still see why it spoke to me so deeply. The only difference this time around was that now I've spent two years of my own life actually working on this issue rather than just researching it for school, and I've come across so many of the issues that Elizabeth Pisani talks about in my own life that it's frankly alarming. That so little has changed in the near decade since the book came out is a travesty. My work with people who use drugs has given me a pretty good idea of the lack of existing political will that would make the health of people who use drugs a priority. There have been encouraging steps forward in some areas, but there is still so much more to do. (For specifics of what those seemingly straightforward solutions are, I encourage literally everyone to read this book.)

Elizabeth Pisani is unflinching in her delivery of the realities of working in the field of HIV and her no-bullshit explanations of why we are failing so badly in getting HIV under control is eye-opening. She says so much of what needs to be said. If we could just get some more people saying it, maybe we could do better for the people who would genuinely benefit from the industry getting its shit together.

Original Review: "The Wisdom of Whores" immediately captured my attention with its thought-provoking title. The book within the cover just served to draw me in further. Elizabeth Pisani brilliantly captures one of the main obstacles in dealing with the HIV/AIDS crisis - sometimes smart people make bad choices. This is just one of the simple, yet brillint insights provided in this book; I couldn't put it down.

I have been studying HIV/AIDS for several years, and never has a book on the subject spoken to me in such a profound and meaningful way. In fact, due in large part to the world I was exposed to through Pisani's writing, I am now applying to my Masters in Epidemiology. Never underestimate the power of an excellent book.

[Brendan Conner · Rating 3 out of 5]

Elizabeth Pisani’s book, The Wisdom of Whores: Bureaucrats, Brothels and the Business of AIDS, while choc-a-bloc full of policy and statistics, lacks the whore’s-eye view the title first leads the reader to believe. While The Wisdom of Whores is certainly a well-written and eminently useful insider’s take on international HIV/AIDS policy, I fail to see the relevance of the title. Pisani’s Whores actively calls into question the very “Sacred Cows” of sex worker rights and HIV/AIDS activism: the rejection of compulsory testing as inhumane, the prioritization of antiretroviral treatment, and, activist’s full-on endorsement of peer education among high-risk groups: commercial sex workers, injecting drug users (IDUs), and men who have sex with men (MSM).

This titular technicality out of the way, I’m not sure I entirely disagree with Pisani’s take on the matter. The strength of this book, in my view, is its ability to shake up the treatment and prevention debate among sex workers themselves. Perhaps it’s time the "golden cows" of sex worker rights, as Pisani puts it, were recast.

[Sue Online · Rating 4 out of 5]

I am getting older. Yes yes, I know we all are, but this is my story, so shush yourself. I am getting older, and so are my family and friends and colleagues. Not all, mind you, but enough. Too many. I’m watching them age, and I think to myself, they are getting smaller. They are shrinking their worlds, their experiences, their understanding of the world. The world that changes. They are not keeping up, they are not challenging their own conventions and beliefs. Maybe they aren’t getting smaller/. Maybe they are staying the same, but it’s the world that’s getting bigger.

As an old school lesbian feminist, I was around before AIDS and HIV. Not much more, mind you – I am not that old – but there was a time, just off the edge of my consciousness, when there was no AIDS, no HIV, no GRIDS. I’m not kidding myself, it’s a disease older than me, but it just wasn’t, well, here. Here is the gay community, here in the outer world. It wasn’t here. And now it is.

Back I the early 1980s, or maybe the mid 1980s, I don’t exactly recall, I started doing my thing for HIV and AIDS. At the time we didn’t distinguish. It was AIDS, or full blown AIDS. Life expectancy was low and political activism was high. It seemed like the entire community was dying, or at risk of dying. We had to take charge because no one cared about us, no one cared about the [insert hurtful homophobic word of choice] and the [insert another hurtful homophobic word of choice]. We were left to die, it seemed, so we said F-you and didn’t die. We fought back, we created a new reality and, kicking and screaming, we brought the whole rest of the world with us.

Now when I say “we”, I don’t mean me. I did my time in the early years, but then the movement changed. People with AIDS needed to care for people with AIDS. The rest of us were sources of money and not much more. I have one friend who dedicated more time to fighting AIDS and helping people with AIDS than just about anyone I know – and I am talking at least a decade here – despite the fact that as a straight woman without the disease she was judged The Lesser. She persevered when many of us gave up, and I wonder how many people are alive today because of her. She knows who she is and if anyone never said thank you: THANK YOU!

My time on the AIDS front faded quickly at the time, and has hovered just above indifferent since the 1990s. I donate or donated to the AIDS Committee of Toronto and People with AIDS Foundation, CANFAR and AMFAR, and World AIDS Day. I have a Product RED iPod and my Product RED Starbucks card and I donate occasionally. I’ve accepted my role as money giver just as much as I have accepted the fundamental truths – I think Elizabeth Pasani calls them “Sacred Cows” – and I have never really questioned them.

But (and here’s the tie-in you’ve been hoping for), one of the ways to make sure that as you grow older you don’t grow smaller and staler, is to challenge your long-held beliefs with an open mind. I am not saying you have to change your mind, I am saying you have to challenge your mind.

Elizabeth Pasani does that, and more. There were a few times I wanted to put down The Wisdom of Whores, a few arguments she caused between Kelly and I (which is *really really* rare, trust me), and a few times I thought… she is freaking brilliant!

Yes, she hit me right in the iPod: “HIV prevention programmes that don’t focus on reducing the likelihood that infected people will pass the virus on to uninfected people make governments, votes and even people who buy Bono’s red iPods feel like they are tackling the HIV epidemic when in fact they are completely missing the plot.”

Wha? Who does she think she is? Oh, she’s a scientist, an epidemiologist who has travelled the world dealing with AIDS. Okay. Yes, she knows way more about this than I do. And her perspective on the AIDS epidemic is very challenging indeed.

I won’t go too much into what her theories are and what formed her outlook, but no matter what you think about AIDS, she will challenge it. She even challenges herself and admits when she comes up short and can’t believe what she ought to.

So who is this book for? It’s for 5 different kinds of people:

1. People who know little about AIDS
2. People who know everything about AIDS
3. People who don’t know what to think about AIDS
4. People who don’t give a damn about AIDS because more people get cancer, dammit!
5. People who don’t want their world to get smaller as they get older, but want their world to become bigger than they ever dreamed

If you fit into that group, read the book. If you don’t fit into that book, well then, have yourself a nice little life.

[Eleanor]

This is such well written and compelling stuff, even if it is sixteen years old and therefore missing analysis of recent developments like the availability of PrEP. Pisano, a UN epidemiologist, proffers a window into international development thinking at the time of the book’s publication (and perhaps now too): the idea that HIV/AIDS is a development issue, caused by generic “poverty” and “disempowerment”, was well-meaning but fatally wrong. She argues passionately that the big bucks from the philanthropic HIV industrial complex need to be spent on things that don’t look cute (like mothers and babies) or make good sound bites; instead, the greatest difference can be made in making risky behaviours around sex—mostly commercial/transactional sex—and drug injection safer. These include needle exchanges and incentives for condom use. But, as she dryly puts it, there aren’t any votes in doing nice things for junkies. I occasionally found some of her language to be unnecessarily combative, and some of it (especially in relation to trans sex workers) is of its time. Clearly, though, she’s no ideologue or bigot: she wants to save lives, and the numbers point to solutions that politics doesn’t like. Extraordinarily clear and engaging writing, too; Pisani’s first career was in international journalism and it shows. Well worth reading. Source: passed on by Rebecca—thank you!

[angeannie · Rating 5 out of 5]

This book was very captivating and I think it beautifully explained the struggles of epidemiologists and addressing health issues around the world. Pisani had interesting insights and examples that kept readers going and caring about those who HIV attacks. I definitely would recommend and re-read!

[Michael Connolly · Rating 3 out of 5]

The author is a journalist-turned-epidemiologist. She has a master's degree in Classical Chinese from Oxford University. She also speaks Spanish, French and Bahasa Indonesian. She has a doctorate in Infectious Disease Epidemiology from the London School of Hygiene & Tropical Medicine.
Pisani is very outspoken. She criticizes the political Left for saying that AIDS is a threat to everyone, because it takes the focus away from high-risk groups such as prostitutes and drug addicts. She also criticizes the Left for asserting that poverty is a primary cause of the AIDS epidemic, because it concentrates aid on the poorest people, rather than those at most risk for AIDS. She criticizes the Left for asserting that routine HIV testing stigmatizes homosexuals. She criticized the political Right, for its objections to providing addicts with clean syringes and prostitutes with condoms. She is critical of feminists, for pretending that African women are pure victims of husbands who sleep around, but not admitting that many young African women are also promiscuous. Pisani points out that the main path for the infection of young African women is their association with older men who have more money than young men.
Besides condoms, she also emphasizes the use of sexual lubricants, because they prevent skin tears that can let the AIDS virus in. She also mentions that other STD's, such as herpes and syphilis, increase the risk for HIV infection, because the skin sores offer a route into the blood stream. Male circumcision substantially reduces transmission of the AIDS virus.
Pisani says that countries, such as Uganda, whose governments speak openly about AIDS, drugs and sex do a better job restraining the epidemic than those that are less candid, such as South Africa.
Pisani is not just a bureaucrat who sits behind a desk. She has spent a great deal of time in Indonesia talking with people in high-risk groups. She is a believer in the idea that the perfect is the enemy of the good. Sure, it would be nice if there were no drug addicts, no prostitutes, and no cheating husbands, but given that no one knows how to change human nature, we should concentrate instead on the prevention of the transmission of the HIV virus among high-risk groups.
Pisani talks about the waria of Indonesia, who are a third sex, people who are physically men, but think of themselves as women. Most of them do not want a sex-change operation, even if they could afford it, because with the loss of the penis would come the loss of the ability to experience orgasms. Waria who are sex workers do not have pimps. I was surprised that Jakarta was such a wild place, since Indonesia is a Muslim country. Pisani mentions that following the lead of the West, homosexuality has become more open in Asia in recent years. Another surprise was the high variability of the frequency of AIDS between different places. For example, there is almost no AIDS in East Timor, especially since the Indonesians have left.

[Guillermo Jiménez · Rating 5 out of 5]

Además de un estilo magistral para dejar claro su punto sobre la relación sexo, drogas y VIH/SIDA, Pisani logra que hagamos un recorrido con ella, a lo largo de su libro, sobre cómo la humanidad nos las ingeniamos para hacer cosas realmente estúpidas, perdiendo completamente de vista incluso que nuestra vida puede estar en riesgo, solo por buscar nuestro placer.

No se refiere solo al placer sexual o recreativo de las drogas, pero este par sí abarca demasiado cuando se habla de HIV/SIDA.

Por un lado eso, por otro, esta impresionante mujer, se encarga de abrirnos los ojos en cómo la metodología a la hora de investigar puede echar todo a perder, o tergiversar la información, "torturar los datos" para obtener lo que quieres resaltar; y como todo esto parece estar peleado con la política. Gran problema, puesto que es la política quien decide a dónde va el dinero que se recauda para dar pelea a esta enfermedad.

"La ciencia no existe aisladamente. Existe en un mundo de dinero y votos, un mundo de ruedas de prensa y lobbies, de farmacéuticas productoras y de activismo medioambiental y de religiones e ideologías políticas, y todo el resto de complejidades de la vida humana" (13).

Y no es que esta enfermedad sea la única. No, pero, de una manera sumamente completa, Pisani se encarga de unir todos los puntos que están a su alcance y nos brinda un cuadro muy completo de por qué deberíamos prestar atención a este problema y, al menos, presionar a nuestros gobiernos a que hagan lo que realmente debe hacerse y no lo que creemos que es mejor.

Se apoya en datos, datos, datos, investigación. Acepta cuando se han cometido errores y aprenden de ellos, y vuelven a obtener más, más investigación, más entrevistas, más investigación de campo, y entonces, se vuelve a publicar informes, reportes, se trata de torcer los brazos de gobiernos, fundaciones, y demás.

Su estilo es increíble, muy autobiográfico, muy personal, la razón del libro en sí es porque ella está en el ajo, porque ese tema le ha llevado más de 10 años de su vida y es muy frustrante ver que en esos 10 años ha habido avances, pero, aún siguen cometiéndose graves errores.

Si hay libros que te pueden cambiar la forma de ver el mundo una vez terminado de leerlos: este es uno de ellos.

[Dasha · Rating 3 out of 5]

This book has high highs and low lows. On the whole, I think it is a worthwhile read, even if it is a bit old. Pisani is a good writer and provides a critical and insider perspective on HIV research and politics that is incredibly interesting (I mean, I didn't expect Billy Graham to pop up in this narrative). I found her discussion of waria in Indonesia interesting, as its a topic and group I had never previously read about. And while she clearly presents her perspective she also highlights the voices of the waria themselves.

The lows include her very very dismissive discussion around sex trafficking that boils down to "I haven't seen it so it's probably over-reported" and her dismissing one woman who told her she was sex trafficked by her family by quipping "I'm sure her life story would make a good movie." I could say HIV isn't a big deal because I haven't interacted with anyone with HIV at the hospital I worked at, but of course, that's stupid.

[Guillermojimenezespneo · Rating 5 out of 5]

Hay quienes cruzan el infierno o nadan en el río que lleva a él y como los intocables, surgen más puros o más humanos, lo que escojas como resultado. En la lucha contra la enfermedad humana, SIDA o malaria o lepra, o plaga o el cáncer, hubo y hay quienes trascendiendo su historia primate o irracional, dan resultados, contienen o contribuyen a su contención y retratan lo mejor del ser, de lo profundamente humano, sin lágrimas ni conmiseración ni pena. Son faros, iluminan la temible oscuridad de la ignorancia y del prejuicio y nos brindan un motivo de regocijo, aunque sea pasivo. Claro que hay datos, porque no basta con las palabras, porque los datos son un reflejo más fiel de la realidad, ¿cierto?, probablemente así sea. Puedes saltarte los datos y las referencias y escoger leer el núcleo y las vidas de los enfermos y de sus luchas por sobrevivir, parias de la evolución, inadaptados de la selección natural, pero al fin hijos de Darwin. El SIDA llegó y estará con nosotros hasta el fin de los tiempos humanos o hasta que modifiquemos el genoma individual y la lucha personal contra tu enfermedad. Siempre hay alguien que vela por ti. Y no es Elohim o cualquier otro nombre del dios de los coléricos, de los intransigentes, en suma, de los que no son humanos. Gente como Elizabeth. Aleluya.

[Wealhtheow · Rating 3 out of 5]

Pisani has been working in AIDS research pretty much since its inception, at all the big organizations: UNAIDS, WHO, CDC, World Bank, Ministries of Health in China, Indonesia, East Timor, and the Philippines. She tells the story of the evolution of AIDS programs, which started out as shamefully poorly funded and are now overwhelmed with badly managed donor money. Personal and political ideologies have blocked the most effective programs, channeled money toward populations that don't need it, used resources in the most inefficient ways possible (for example, when she wrote this book most US aid was tied up so that a program in Asia would have to buy condoms made in the US and ship them across the world, as opposed to just buying the much cheaper condoms made locally. Same problem but on a grander scale with drugs, which pharma companies made a mint off of, even after Brazil and India rebelled against their patents and started making their own generics)...Pisani has a light, cheeky tone for most of this book, but hints of righteous anger filter through, mostly in the form of bitingly sarcastic footnotes. God, I love sarcastic footnotes.

Definitely worth a read if one is interested in donor aid, AIDS, or the research of infectious diseases.

[Stephy · Rating 4 out of 5]

Having been on the front lines of the AIDS epidemic in the United States when it was still called GRID, (Gay Related Immune Deficiency) I have watched in stunned horror as our Government refused to earmark money for AIDS education and research, and limited money to countries that were, sensibly enough, distributing condoms to sex workers and people with multiple partners.
I have been far too close to the actuality of people dying to stand back and get this broad overview. I'm delighted that Elizabeth Paisani has written such a book. Taking care of people who are living with, and in the beginning, drying from AIDS opportunistic infections, was an exhausting experience, physically and emotionally. many of us who survived are still in a kind of shock. This book had more about how organizations work than I ever cared to know, that is true. Primarily though, it is an honest appraisal of how AIDS and the the people and governments of the world have interacted since it all began. I highly recommend this book.

[Alicen · Rating 4 out of 5]

This book is a searing commentary on the state of the HIV/AIDS prevention/treatment world- or at least the author's take on it. I really appreciated, however, her criticisms and critiques and think that it's important to be constantly analyzing and re-analyzing one's work and field. Some will find this book controversial and it is in many ways, but she also has some useful comments. Great for anyone working this field or interested in understanding some of the complexities in the HIV/AIDS world.

[Cindy · Rating 3 out of 5]

This is a damn good book and should be read by anyone even tangentially associated with the aid (and, better yet, AIDS) industry. Having recently left yet another big international development mtng, I sympathize with both Pisani's passion and frustration with the perplexing way in which development resources are used.

[Dean Rizzetti · Rating 5 out of 5]

Elizabeth Pisani knows how to make banal things sexy. I’m not convinced that a job writing manuals at UNAIDs or consultancies helping government setup monitoring systems is really the stuff that gets the heart pumping. But Pisani trounces my skepticism, using her experience as an anchor for compellingly, well-argued observations about development, research and HIV.

The first third of the book is focused on Pisani’s transition from a journalist in Hong Kong to a scientist writing cook-books on monitoring HIV at UNAIDS. This technocratic post ultimately turned into a job tracking Indonesia’s HIV rate, wandering the back streets of Jakarta asking prostitutes about their practice. This is the foundation for her broader assessment on research and the way we use the data we collect.

Two points in this discussion really stood out for me. The first was a round-about but ultimately spirited defence of qualitative methods. As Pisani admits, it easy to dismiss qualitative research for the hard certainty of numbers. It can be very wishy washy, and the quality of data is hard to assess. But under this certainty lies a lot of mushy, rusty assumptions. How, for example, should you quantify a man who sells sex to men, dates a street walker and visits cross-dressers from time to time, all the while resolutely claiming to be straight. He doesn’t fit any of the UNAIDS boxes of a female prostitute, gay man or drug user, which leaves him without a box in the AIDS monitoring cookbook. But he’s clearly at risk - with so many chances for the AIDS virus to enter his bloodstream. These blindly obvious challenges only come to the fore when we ask questions to really understand what we’re studying. But when we rely on numbers we often avoid first understanding who or what we’re actually to measure.

The second blindingly good insight was the data spin cycle. Early in the life of UNAIDS, there was a problem - AIDS wasn’t growing fast enough in the right places for anyone important enough to notice. Absolute rates were skyrocketing in places no-one cared about, but were stubbornly small elsewhere. However, with a quick in the interpretation of the data from absolute numbers to rate of change, suddenly important places were experiencing an epidemic. This was something you could build a movement with (which UNAIDS did with admirable efficacy!). But ultimately, the statistically story rested on spin - both concerning and impressive.

As the book opens up, the argument expands from Pisani’s direct experience into a broader take on HIV. Pisani spends a fair chunk of the book on Africa, which has overwhelmingly borne the brunt of the HIV epidemic. At the time of writing, "a schoolgirl in South Africa was thirteen times more likely to have HIV than a sex worker in China, while a civil servant in Swaziland is forty times more likely to have HIV than a junkie in Australia”. And what drives such incredible transmission in hetrosexual people? Sex with multiple partners at a time when your viral load is high. For most people, this is the first six months of infection and the last few months before death. Assuming that you don’t share infected blood or have anal sex, this is the time that transmission is likely to occur. And for transmission to occur in this period you need to have multiple partners, across generations and within marriages. African politicians tried to avoid this fact, abetted by international bureaucrats who focused on poverty, gender or basically anything but sex. Leaders who were willing to focus on sex like Uganda’s strange-hat-wearer in chief Musevene saw HIV rates decline, while others watched people die.

As someone who works on climate change - a field that can be similarly distracted by beat-ups and focusing on the wrong issues - I found Pisani’s focus on the facts of transmission really compelling. In the climate change world, we spend a lot of time worrying about a lot of issues that do nothing to reduce emissions. Similarly, in the HIV world, Pisani argues, we spend a lot of time funding interventions that won’t help reduce actual transmission rates. It might be nice to focus on the general public but the truth is that if you want to stop transmission you have to go to the virus, which thrives amongst the politically palatable populations of sex workers and drug injectors. Spending 99% of your budget on the general population (as Ghana does) is unlikely to make any difference to HIV when 76% of your new transmissions happen in commercial sex. Taking action requires us to look deeply at cause no matter how uncomfortable and focus religiously on the bottom line, no matter how compelling the co-benefits of an ineffective policy might be.

The final third of the book is dedicated to sacred cows. Yes, Pisani argues, ARV treatment can increase HIV rates as people get lazy. No, infected populations are not always the best placed for designing interventions. And yes, Government can actually play a useful role in treating HIV, while NGOs often can only scratch the surface. Pisani provides a great anecdote to illustrate the point. Thailand is home to one of the world’s most effective HIV treatment programs through targeting the people with the greatest economic incentive. The Government held brothel owners accountable for ensuring their clients used condoms. Women were tested fortnightly for STDs, and men who showed up at health clinics with gonorrhea were traced back to the brothel. If gonnorhea was present, then odds were that condoms weren’t, and the brothel owner was shut down. Condom usage went up 90%. This was primarily because Government had the reach and enforcement power - this wasn’t a bottom-up, client driven approach. It was a "mediocre service provided to a lot of people”, which is often far more impactful than the most attractive but limited services of NGOs. The final telling piece of wisdom was that Thailand payed for 75% of this program out of their budget, with donors making up the rest. For those of us who spend their time trying to get developing countries and communities to care about as issue, this should be a number one indicator - will the government or community actually pay for the service? If not, are we really sure it’s what they want?

A lot of people have fretted that this book wasn’t actually about providing the wisdom of whores. But that’s fine; this is the wisdom of someone who has been in trenches and kept her head down long enough to come up with some blindingly good wisdom of her own. A great book for someone who doesn’t know a lot about HIV and perhaps an even better book for someone working in development.

[Pablo · Rating 5 out of 5]

“Un trabajador de una ONG en Birmania me dijo que solía entrenar a trabajadoras del sexo como investigadoras, pero no sentó bien entre las chicas encuestadas. "Decían: ella es tan puta como yo. ¿Por qué tendría que decirle nada a ella?" Ahora viste a todo su equipo de investigación con batas blancas y accesorios médicos. Los estetoscopios dan el pego. "Si piensan que eres médico, te abrirán su corazón”

¡Me costó un montón de tiempo terminar este libro, pero por fin lo pude conseguir! xD

La historia que nos cuenta Elizabeth Pisani en este libro es tan sorprendente como alarmante. Gracias a su experiencia como epidemióloga trabajando para la ONU en los primeros días del programa del VIH/SIDA, es que podemos descubrir toda la política y los negocios que rodean el mundo de esta enfermedad, en donde lo económico prevalece sobre la población, en la mayoría de los casos, en territorios inhóspitos donde el dinero de los EEUU llega por medio de donaciones (El país americano es el que más invierte en VIH/SIDA para los países en desarrollo, pero lo hace por medio de condiciones ideológicas y políticas que como dice Pisani en varios pasajes de este libro, entorpece las investigaciones y los programas en pos de mejorar la calidad de vida de los que no pueden acceder a un tratamiento de antiretrovirales o a los métodos de prevención de la enfermedad).
La razón de por qué demoré tanto con este libro fue debido a que la primera mitad se me hizo muy lenta; pero cuando llegué a la segunda parte todo se tornó trepidante y a ritmo de thriller, por lo tanto no pude parar de leer.
Estoy muy contento de que este haya sido el libro con el que cierro mis lecturas de 2019, por todo lo que me enseñó acerca de la industria farmacéutica, médica y política. Creo que la mejor lección que deja es que siempre que miramos un estudio epidemiológico realizado en países en desarrollo o de regiones de bajos recursos lo mejor es buscar los datos del/los investigador/es que lo realiza/n, los datos al pie y quién financió el mismo. También abre los ojos acerca de quiénes son los que en verdad trabajan para cambiar este problema mundial de salud pública que es el VIH/SIDA y los que sólo lo hacen por un interés económico (Desviar fondos hacia otros países) políticos (Quedar bien con cierto número de votantes) o religiosos (Mediante la realización de programas escritos pos instituciones católicas con muy poco contenido de realidad).

En fin, espero que si en algún momento tienen la oportunidad de leerlo (No llegaron muchos al mercado Uruguayo, les tiro este tip por las dudas) espero que lo disfruten tanto como lo hice yo.

¡Feliz 2020 para todxs!

[Desca Ang · Rating 3 out of 5]

The review is taken from my IG account @descanto

The Wisdom of Whores seems like a real deal. It's been in my TBR stack for ages...lol. It's always so many book and so little reading time. Anyhow, people may think that it's all about unveiling the world of prostitution. Yet it's Pisani's memoir and an honest assessment on analysing and working in HIV/AiDS epidemology. She covered the analysis in the Western, Asia (mostly Indonesia and Thailand) and African contexts. It's written 10 years ago so it may be a little bit outdated to the recent cases.

In this book, Pisani pointed out that HIV/AIDS funding are often the hardest parts. The hardship of local NGOs in promoting their programme regarding the prevention and spread of HIV/AIDS with the limitations of funding is written here. A point she keeps coming back to is that we'll never get the HIV epidemic truly under control until we both acknowledge that it's these stigmatized groups like gay, prostitutes and waria who are at highest risk and care to do something for them.

The Wisdom of Whores is not Pisani's first book that I've read. I've read Indonesia, Etc and it's mind blowing. This book the Wisdom of Whores (to me) only switch more into memoir than insight mode and its mixture is a little bit chaotic leaving me "all flat." Oh no..no! It's not because the book is bad-written. It's just getting too repetitive in the second half leaving me with my eyebrows raised while murmuring, "tell me sumthin I dunno..." Yet I'll still acknowledge that it's important to know how hard international HIV/AIDS work and its preventions is and Pisani's book gives a view into what it takes to save lives in the department.

[Serian · Rating 5 out of 5]

I thought this was a really fascinating book - about AIDS, about international organisations, about epidemiology, about statistics, about health, about people.

It's incredibly readable and straightforward but still manages to explain really complicated issues. I liked the way Pisani structured it around her own life and career, though that might not appeal to some other readers. I did find myself getting a bit bored of her disdain for political correctness - the point really didn't need to be laboured so far - and there are areas where I think she oversimplifies. But overwhelmingly I think these were responses to the existing literature/debate and they're minor niggles.

I borrrowed this from the library, but I'm definitely getting my own copy!

[Natália Heriban · Rating 5 out of 5]

Z mojej perspektívy knižka hlavne o tom ako nonstop treba presviedčať kompetentných že aha tu sú dáta toto sa deje tým ľuďom a keď spravíte toto lepšie bude. Nepomôžem si a proste pri čítaní mi aj tak nonstop vyskakuje to že prosím nesúďme ľudí a neveďme nonstop filozoficko-moralistické debaty o ich životoch - robme s realitou a realita je taká že áno ľudia majú sex a dokonca niektorí aj drogy berú *vau vau*

[Lucy Gray · Rating 4 out of 5]

Overall an incredible overview of the history of international HIV/AIDS funding/prevention/treatment efforts — I learned so much!

I mostly liked the author’s style of writing, kind of gossip-y and travel guide-y in a way that made the nitty gritty statistics and things less boring. Some parts definitely have not aged as well

[Cían · Rating 4 out of 5]

As an epidemiologist I learned more about social determinants of HIV than in any lecture or textbook
Although incredibly informative and factual, the book delivers through stories and narrative which is incredibly interesting and astonishing. The language is so comedically blunt.

[Erin Cook · Rating 5 out of 5]

Brilliant. My friends who have all read this before will be pleased I finished it, because I can't stop talking about it

[Walidah & · Rating 5 out of 5]

I wonderfully written book!

[Ocrema · Rating 5 out of 5]

The book is totally cool.

[Julia · Rating 4 out of 5]

Once in the book there was a spelling error that called it the Widom of Whores and mentally that’s what I called it for the entire rest of the book lol

[Jite · Rating 4 out of 5]

Fascinating take on the global AIDS epidemic!

I am not huge into non-fiction but as someone working in public health who saw this listed as the first book of the APHA (American Public Health Association)’s new book club, I decided to check this out. It’s the kind of book I read in grad school but wouldn’t have necessary have selected if not for the book club. Or so I thought.

The “Wisdom of Whores” is a fascinating take on the global AIDS epidemic that was written about a decade ago, but which is sadly still very relevant in talking about the way we address not just AIDS policy and programming, but health policy and programming in general. The author focuses on talking about all the missed opportunity, wasted funds, things we’ve done wrong over decades of programming. Her thesis looks a lot at the dichotomy between science and evidence and ideology and self-interest, between epidemiology and politics and between plain-speaking and political correctness. In short, Elizabeth Pisani is not shy to list EVERYTHING wrong with AIDS programming and believe me, the list according to her, is long. She is not interested in prevarication or sensitivity and will step on any toes required to get her point across and she is intentional in this- from the start of the book, she tells you of her fatigue with all the pussyfooting that goes on in the AIDS discourse, in her opinion, getting in the way of the plainspeaking that might bring about useful discussions and actual change. She, like everyone who works in the field, is very convinced of her own ideologies and as a scientist (specifically an epidemiologist), she puts out her data to convince you that she is right, and in fairness, she is very convincing.

As a reader of this book, and as someone from a developing country, it needs to be said that this book is not for “us.” By us, I mean readers from the countries that would be defined as “most affected.” Pisani‘s writing about developing countries is what I imagine colonialist’s who first arrived African shores sounded like in their clinical anthropological descriptions of “the natives and their ways.” Whilst Pisani is equally scathing about Western leaders, there is certainly a degree of condescension when she’s writing about certain regions (Africa being one). Even her beloved Indonesia doesn’t escape her patronizing tone at times. Once I recognized that this was not a book that was afraid of sounding racist or bigoted or condescending (she warns you early on) and once I realized that I was not the target audience for this book, which seems more aimed at whistleblowing funders to their constituents (tax-payers), I was pretty much unoffended.

The book title is pretty accurate. This is not one of those pop science book that promises you one thing but delivers dry textbook biscuits that no one is interested in reading. If anything, the title is underselling just how “red light district” this book is. She might have called it “Sex, Drugs and HIV” and that would have been an accurate summary because basically, all the science is viewed through the lens of the human pursuit of pleasure above all things even common sense. I learned a lot more about sub-cultures and sexual and injected drug use networking in developing countries than I’d ever known before- from proper sex workers to warias (transsexual sometimes prostitutes) to rent boys, to men sleeping with men who don’t identify as gay, to “faithful” couples who occasionally sell sex, to injected drug users who know better than to share needles or inject drugs but do it anyway... the list is endless- the high risk subcultures numerous and if anyone is treated with compassion by the author in this book, it is these very high risk populations who according to her get the least focus and the least programming even though they have the highest need. And because of the compassion with which Pisani treats these populations, you’ll find your compassion towards them increase.

My takeaway from this book is that Elizabeth Pisani comes across as a lover of pleasure, an asked of questions, a shaker of tables, a master of data, a know it all, a condescending so-and-so, a compassionate supporter of the underrepresented and many other things along those lines. However, she’s not wrong in her call for interventions to be more evidence-supported and less based on feelings, ideologies and self-interest. I highly recommend reading this book if you’re even vaguely interested in sex, drug use and HIV programming.

[Rik · Rating 5 out of 5]

This book gives a great overview of how the aids epidemic was handled as described through the eyes of an epidemiologist. I agree with some people that the author sometimes seems to preach her views. She very much sees the world of policy making in a rational way. Find the best evidence and implement that, very simply said. However, I believe it happens more out of an incremental model. But that's another discussion. Great book!

[Rachel · Rating 3 out of 5]

A good friend recommended this book to me, and I can see why. Pisani is really very good at explaining epidemiology in layman’s terms – and I speak as someone with a medical degree and a public health degree and who still struggles with the maths of it. Her experiences working in AIDs public health advocacy, and the descriptions of how this changed over time and geography, are interesting and valuable.

However. As Pisani herself states at the book’s opening, her original training was in journalism. A big part of her job in the early days, when there was more disease than money, was ‘beat up’s of the data: in other words, selecting the juiciest correlations and presenting them dramatically. Which is fair enough, on some levels, and is also proof – if any was needed – that even the all-holy quantitative data is not one hundred percent objective one hundred percent of the time. However, she’s hoist on her own petard at certain points of the book. She has some insight into her own limitations – for example, she couldn’t deal with her husband’s drug addiction, even though she spent her working life trying to help drug addicts with HIV. All the same, some of her offhand comments are eye-wincing.

From early on, she’s also critical of governments not funding enough international aid.

‘But this alone did not seem to be enough to spur rich countries or even international organizations to come up with much cash.’

This is page 29; my note says ‘is it their job tho’. It’s not an evil thing for richer countries to help out poorer countries, but the chippy, argumentative, anti-status quo Pisani never seems to wonder why it is that rich and poor countries exist in the first place. The benevolent imperialist, interfering for the heathen savages’ own good, has now been replaced by the benevolent philanthropist. Is this better? For Pisani, the answer is yes, but she never actually poses the question. Which, to me, is a significant limitation.

It gets worse, though.

‘Public health is inherently a somewhat fascist discipline. It accepts that we must sometimes violate the rights of a few to protect the health of the many. Look at SARS. When that crawled into view we slapped restrictions on people’s movements.’

Given what happened with COVID, the fascist description is not unfitting. What’s weird is how pro Pisani is on this.

‘Small NGO- run interventions can make a huge difference to the lives of the people they touch. The problem is, they don’t touch many lives. Local NGOs are like high- fashion boutiques. [...] But they have done it on such a small scale that it has made no difference to the epidemic.’

But it made … a difference … there? I mean, on one hand she describes how AIDS became a ‘growth industry’ with a sugar bowl of money attracting many ants. She rails against the waste and inefficiency: ‘It was as if surveillance was an activity in its own right; a slightly inconvenient annual procedure that just had to be ticked off, like signing up for the electoral register or paying your road tax.’ And: ‘Most of the bidders are Beltway Bandits– organizations which squat around the Washington DC ring- road, never far from the comforting nipple of USAID. When the government announces a new contract, the Bandits leap into activity, writing proposals that show how cleverly they will spend the money. Or rather what’s left of the money. The Beltway Bandits slice between 15 and 30 per cent off the top before they ever pass it on to a country office, presumably to pay for the money spent bidding for proposals that keep people like me in a job.’

But on the other hand, she appreciates that what works in one place won’t necessarily translate to another. So what is she actually trying to say? Small local tailored interventions are shit, but so are big international umbrella ones? I mean, pick a side, Liz. Or is it just that she wants them to do what she says, at all times? Ultimate White Knight Elizabeth Pisani?

‘And you almost never have to show you’ve prevented any infections. You can be judged a success for just doing what you said you were going to do, like build a clinic, or train some nurses or give leaflets to 400 out of the nation’s 160,000 drug injectors. It’s a bit like declaring that Ford is doing really well in the car market because they’ve got factories and floor managers and an advertising campaign, instead of looking at sales figures. Or even checking that they make cars that run.’

Michael Hobbes of the Maintenance Phase podcast is so funny on this topic. The Sounds Like a Cult podcast also did an episode on NGOs. I didn’t agree with some of it (and indeed the premise of the show speads itself so thin it risks its own integrity), but fundamentally NGOs want to stay in business more than they want to do anything else. Which is the problem with NGOs. And which is why GOVERNMENTS SHOULD BE DOING IT.

‘Actually, what we really need might be more people like Bill and Melinda Gates and squillionaire Warren Buffett. These New Philanthropists have the potential to change the face of international public health, because they have gobs of cash and no voters to answer to. Of course, they still have to play nicely with governments in the countries where they want to work, but they are in a better position than most to tackle projects that governments are nervous about taking on themselves, and to do them on a scale that might make a difference.’

ARGH ARGH ARGH ARGH

How. How can you see such fundamental problems with the US pushing abstinence-only sexual education at home, and wielding its undue financial influence to push it abroad as well, with untold detriment to the health of millions, and think: what we need is LESS DEMOCRACY and LESS OVERSIGHT. What happens when, as is already happening with Bill Gates, you take a turn on your moral stance on certain subjects and decide to withdraw that lovely funding? Also, I don’t AGREE with countries who want to restrict women’s healthcare or think HIV is a myth or whatever, but I also don’t seen that white knighting in as a foreigner is the SOLUTION. If your government doesn’t represent you, that’s on you. It really is. The government IS US. In countries where there’s no democracy – and Pisani is unquietly admiring of the way Iran and China dealt with their HIV problem – it’s the duty the citizens to change that.

I dunno. Maybe this is a factor of this book being written in the early 2000s, when she was closer to the End of History than the Rise of Neofascism. But I also think there’s simply a fundamental error in her thinking, which can be summed up as confusing the general and the particular.

‘In the time we sat chatting, four lots of clients were turned away, and only two deals were done (one with men in a BMW with plates from China’s gambling epicentre of Macao). The ‘all sex workers are trafficked’ ideologues may damn me for saying so, but these ethnic minority women, working at the bottom end of the sex trade in one of the poorer areas in China, did not seem to be driven by desperation.’

Again, it’s a fair point, and one that seems to lack sufficient data in either direction: how many sex workers are truly trafficked versus making a pragmatic choice between a limited array of unpleasant options? Or even – as we’ve seen from the increasing voice provided to sex workers through social media – doing it for the pure love of the game? However, you cannot draw a conclusion about all sex workers based on one interaction that took place over a few hours.

‘Thinking that these conferences are about putting your arsenal of facts on the table and may the better science win, I suggested inviting Donna Hughes to debate the merits of abolition versus safer working conditions for prostitutes. I was immediately shouted down by sex worker organizations. They felt that it would be counterproductive to debate with someone they believe puts ideology before facts. In the end, we did not invite Hughes to speak. So much for access for all.’

Maybe Pisani has changed her contrarian-for-the-sake-of-it stance on things like ‘platforming fascists’ since 2006 (or, say, 2016), but who knows. She hasn’t impressed me enough with her acumen to want to read more of her work to find out.