The Wisdom of… Epidemiologists?

The epidemiologist Elizabeth Pisani’s recent 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 led me to believe.

While The Wisdom of Whores is a well-written and eminently useful insider’s take on international HIV/AIDS policy, I fail to see the appropriateness of the title. In fact, 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, finally, activists’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).

With this titular technicality out of the way, let me be clear that 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 workers rights were recast, as Pisani suggests. Then again, perhaps not.

Before presenting the more extreme or challenging positions of Pisani’s argument, let me be clear that she softens their blow with plenty of qualifications. While her position is that the “rights-based approach” stands in the way of effective prevention programs, for instance, Pisani grants its limited necessity to stave off discrimination and stigma, and while advocating targeted 100% Condom Use Policy (CUP), the book grants its drawbacks.

The following mock-up of Chapter 5 is meant to be educational in its simplicity. I’ve related her positions in this way to get to the point.

On compulsory testing: “now that we can do something useful for people who are infected, testing the people most likely to be infected is beginning to make sense. Could it lead to people being outed, being stigmatized? Yes. But untreated AIDS has a way of outing people anyway, so you get the stigma and the avoidably early death.” pp. 171

A policy related to Pisani’s sort of compulsory HIV testing is 100% Condom Use Policy, which sex worker-run organizations commonly reject as CUP allows top-down enforcement of condom use and medical examinations by the military and brothel owners while, according to the Network of Sex Work Projects (NSWP), “all the other fundamental violations of sex workers rights that are taking place in their workplaces are so blatantly ignored” by the inspecting regimes. Additionally, CUP compliance risks the livelihoods of brothels and sex workers who fail the examinations. Pisani seems to acknowledge these risks in part, but, from the perspective of effective policy, advocates for CUP insofar as it has been shown to reduce the HIV infection rate. For instance, CUP increased condom use in Thailand’s brothels to 90%. “The programme worked,” writes Pisani. I see her point, but I’m not convinced the measures are passable with CUP alone, minus fair labor practice policies. It isn’t clear to me why NSWP and EMPOWER are wrong about mandatory testing and CUP. From my perspective as a sex worker in the United States, I would reject any form of government intervention. Then again, I work under different conditions.

On antiretroviral treatment: “More treatment means more people with HIV, potentially taking more risk and exposing more other people to the virus. We need to make sure that we have the money and the staff to bump up prevention services as more people get treated. And we need to see treatment as an opportunity to draw people into prevention programmes, rather than let people think: ‘I’m on antiretrovirals, I’m alright, Jack.'” pp. 165

Point taken, especially the second and third ones. The “infected are coming!” point is a bit blunt, but I’ll take it for its accuracy. It’s very persuasive on a purely statistical level, but HIV isn’t just about statistic. It’s about lives and, for us, livelihoods. I’m eager to see counter-arguments by activists involved in sex workers’ rights.

On peer education: “For care services [peer education] has worked exceptionally well.” But for prevention education on the whole, “Being HIV positive does not necessarily make you a good counsellor, any more than being fat makes you a good dietitian. HIV is a virus, not a job qualification.” pp. 183-4.

This point is made with the qualification that, while Pisani finds peer education more sensitive and effective in small-scale endeavors, Whores is looking for a non-NGO “wholesale” approach in which civil servants under governments reach larger groups from high-risk populations, as in the program she was involved with in Indonesia. The difference, she argues, is epidemic in proportions: there are not enough peer educators to meet the need to a tee. There are enough government workers, however, to meet the need imperfectly. I also find this persuasive as a non-expert and MSM and sex worker, but I have the same qualifications Pisani does, only a bit stronger. I think, on the whole, peer educators do provide an essential ingredient of effective prevention and treatment: relatability. Although I agree it says nothing about skill. Then again, when I’ve been granted a place on street outreach, it’s made a world of difference to be with self-identified whores.

To round this back-and-forth review out I’d like to point out, and as Pisani herself points out, The Wisdom of Whores by no means is meant to support all sex worker rights-based, or AIDS rights, positions. In the book, Pisani challenges the core beliefs of all AIDS mafiosos, using her experiences working with street-based waria in Indonesia and injectors, for instance, to explode the mistaken “check boxes” separating the two groups, along with peer education programs’s effectiveness in the first place. All in all, I’d say Whores is a useful title for us to face.


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