Posted tagged ‘Epidemiology’

Poverty and Aids: Who Does What To Whom/Elizabeth Pisani edition.

December 4, 2008

So, to get back to business, a little follow up on the MIT talk by Elizabeth Pisani touted below.

Elizabeth, whose book, The Wisdom of Whores I admire both as a ripping read and as a powerfully argued polemic – with – the -facts, is a passionate advocate for clarity in our description of and response to HIV and AIDS.  A journalist, and then an epidemiologist, as well as a self-admitted member of the AIDS mafia, Pisani emphasizes that HIV is a virus that is transmitted by a few well known pathways: basically unprotected sex, unprotected anal sex, and needle sharing among IV drug users.

In her book and in her talk at MIT on Monday, Elizabeth admitted her own complicity in what she sees as the original sin (my phrase, not hers) of the public health community’s response to the epidemic.  In order to secure funds to fight the disease, public health folks and epidemiologists de-emphasized in public the central roles of commercial sex, homosexual sex and drug use in the dissemination of the virus, choosing instead to highlight more broadly sympathetic and politically acceptable potential victims:  children, “innocent” women, and the ultimately, the public at large.

That spin worked, Elizabeth said, attracting a torrent of money. But there was a catch:  a ton of that new cash was restricted to taking care of the politically attractive categories, leaving the problems at the core of the epidemic — sex and drugs — still drastically under-addressed.

That’s the broad stroke argument, very broad — so don’t blame Elizabeth for my shorthand and no doubt inaccurate attempt at a gloss on her talk. Among her caveats:  much of what she had to say applied not to the two thirds of the epidemic taking place in southern and eastern Africa, but to the one third spread out over the rest of the world.  But the discussion that followed raised two crucial points of contention that are worth thinking about.

One was a reaction to Elizabeth’s complaint of what she did not call, but I will, AIDS whoring.  By this I mean the habit that Elizabeth pointed out of all kinds of (presumptively) well-intentioned organizations trying to claim some connection to the fight against HIV/AIDS, no matter what they actually do, just to take a sip or two from that river of money flowing towards the disease.

In particular, the trope that HIV is a disease of poverty got Elizabeth’s goat.  No, she argued. HIV is a virus, and to the extent that it is a disease of anything….wait for it…it’s one of sex and drugs.

Money spent on projects to alleviate poverty, or to increase women’s economic power, or any of the other entirely important and necessary development goals someone might have will not, in this view, do much of anything to deal with the problem of HIV and AIDS.  If you really want to deal with the disease, she argued, attack the problem directly. Needle exchanges work.  Proper prison HIV projects work.  Condoms work…that’s where the emphasis should lie.

Not so, argued one member of the audience in a conversation after the talk.  Too reticent to push the point during the q. and a., this person argued that Elizabeth was too much the epidemiologist.  From where she sat — a physician with experience in the Middle East, now studying the interface between technology, culture and history in the context of health and medicine — poverty was indeed a significant part of the equation.

That is hard won knowledge, and I’ve heard the same from other people up to their elbows in responding to the epidemic.

And yet, stripping down the question to its core — what will save lives most directly, right now — it’s hard to ignore Elizabeth’s central point:  the argument that addressing HIV/AIDS head on is not the same thing as saying that one should not attack poverty, the evils done to women and or children and so on.  It is just that improved sanitation installed over the next months or years; a new micro-loan program, even one laptop per child is not going to affect the infection being transmitted right now on a thin mattress in a brothel, in the passage from one arm to the next of droplets of blood mixed with heroin, in the late night, alcohol and dance fever-fueled “decision” to forget the damn condom after all.

In this view diseases are not — or at least not only — social phenomena.  From the point of view of someone actually about to be infected, they involve specific pathogens moving through known pathways to inflict harm on identifiable individual people.  And there are methods available, were political and moral will strong enough, to find both those people already suffering, and to reach those near them at risk. Given that capacity, what should the course of action be?

Look at another example:  Paul Farmer has achieved a justifiable fame (some would say apotheosis) through an approach that says you do what you have to do to make sure the miserably poor, no-hoper ten miles away across three mountain ranges takes his or her damn TB meds.

All the medical interventions that Farmer’s approach has generated have not transformed the fundamental conditions of poverty and oppression in Haiti or in other communities where his efforts have been directed.  But they do, of course, save lives — and I’m comfortable with the claim that basic health is a necessary pre-conditions to any such change. Even if you argue that there is an intimate connection between social pathologies and the medical ones associated with AIDS, there is the brute fact of a feedback loop:  poor and oppressed communities, marginalized and reviled groups (think junkies and whores) do not improve their ability to press a claim on the society or polity as a whole when they are mired in the struggle with a spreading infection.

All this, of course, is open to dispute on points of principle.  It is certainly true that absent structural change, the poor and the marginalized have more or less unlimited paths to suffering and death.  Hence, any given amelioration of suffering can be seen as the rearranging of the deck chairs on the Titanic. There is every reason to argue that what is needed is transformative change that addresses blighted lives and communities across the range of problems confronting them.

Fair enough — but in practice, as Elizabeth has described with potent fury in her book, the dilution of AIDS efforts into generalized anti- this or that has does not prevent infections, nor does it, so far at least, seem to have transformed the world of the poor.  There are the usual problems of aid:  those who live well off doing good are always with us, for example.

But more deeply, this seems to me to be a case of the best being the enemy of the good:   There is the blunt fact that structural change is slow and uncertain, and HIV infection and its consequences often are neither.  It is my hope that come January 20th, the worst diversions of effort and emphasis in US global HIV/AIDS policy will be reversed.  Just dumping the abstinence-only set-aside would be a major step forward.  Here’s hoping.

Of course — this begs the question of whether any policy involving culture, society and behavior can work, given the freight that comes with anything involving sex, drugs, conceptions of sin and purity and all the rest…and that came up too in Elizabeth’s talk.

But this post has gone on long enough.  I’ll write up the debate on this point that came out of Elizabeth’s talk in another one.

Jean Agélou, “French nude smoking opium” c. 1910.