More Great Moments in Social Engineering

Giving a fresh take on the AIDS epidemic in Africa, epidemiologist Elizabeth Pisani writes in the Times Online about the nonprofit/NGO feeding frenzy that taps donor funds to combat AIDS in all the wrong places:

HIV is largely a sexually transmitted infection, so there must be something different about sex in Africa. Yet you can’t say that without appearing to be racist. So campaigners have come up with other reasons that HIV is worse in Africa: poverty, ignorance, men having more power than women. All politically correct, but not epidemiologically correct.

The truth is that a society in which many people have two or three partners on the go at any one time will produce a bigger epidemic than a society where people may have 10 partners in five years, but only one at a time. And it’s a fact that in parts of Africa, it’s more common for both men and women to have two or three simultaneous relationships than to have serial partners. Do people behave in this way because they are poor and ignorant? Not in Bangladesh, or Bolivia, or dozens of other countries where incomes and literacy are low. Indeed, in Africa, the incidence of HIV infection is highest in the richest households and the richest countries.

In east Africa, HIV spread first among people who had lots of partners – in other words, men and women who traded sex for money or favours. Had condom use in commercial sex been pushed to very high levels at the time – as happened in Thailand – the epidemic would have been contained.

But most African leaders played Three Monkeys. So a miner infected a prostitute, who infected another client, who went home and infected his wife, who infected her regular boyfriend. Suddenly, HIV was everyone’s problem.

In Africa. Outside the continent, most people infected with HIV are men who have anal sex with other men, people who inject drugs and people who buy and sell sex, as well as their lovers. Indeed, it was these groups that first surfed into public consciousness. Early in the epidemic, the virus was treated as a sign of wickedness, a black mark for bad behaviour. But voters don’t care for the wicked; ergo, politicians don’t care for the wicked. Ergo, no money for HIV.

God knows, we needed it. When I started out in this business in the mid1990s, the world was spending just $250m a year on HIV in poor countries. Later, as African infection rates soared, HIV was repositioned as an affliction of the innocent. The cash started to roll in and, last year, the world spent $10 billion on HIV in poor countries.

When the funding pie was small, HIV prevention meant doing helpful things for sex workers, gay men and drug injectors. Now that the pie has grown to 40 times its original size, and HIV has been painted as almost exclusively a matter of poverty, youth and “innocent victims”, everyone wants a bite.

The UN agencies were the first to jump on to the growing pile of funding, each finding a way to link the blood-borne virus to its own mandate. Other agencies dealing with children, development, economics, labour and agriculture all suddenly found that HIV was fundamental to their work. But the trail of funding hasn’t always taken them in the right direction.

It’s true, of course, that HIV has become a generalised problem in east and southern Africa, where, frankly, it is hard to know what to do about it except pray for better leaders. But what is true of those areas is simply not true for the rest of the world – where the “Aids is everyone’s problem” approach can do a lot of damage. A couple of years ago, I received an e-mail from Save the Children UK, asking for a reference for someone who had applied to be their HIV adviser in Indonesia. I asked why they needed an HIV adviser when only one in 22,000 of that nation’s children suffer from HIV – and most infections are in adult men. The charity would have been better off working on routine health services, education, even sanitation, I suggested. But no, Save the Children would do HIV in Indonesia, come hell or high water, because it was a corporate priority.
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Donors are not supposed to cherry-pick (“I’ll have the orphans, please; thanks, but no junkies”). Yet (Red) has ploughed more than $100m into the Global Fund – and every penny is earmarked for drugs to prevent pregnant women from passing HIV on to their babies, for treatment of the sick and for support for orphans.

In other words, (Red) has chosen the projects that consumers of iPods and Gap T-shirts can feel good about. Because nearly everyone feels good about treating sick people – but preventing them getting sick in the first place: well, that’s a lot more controversial.

In east and southern Africa, two decades of denial and mismanagement have allowed the HIV virus to hollow out whole countries. In the rest of the world, HIV continues to threaten men and women who inject drugs, buy sex or sell it, as well as men who have sex with one another. The lovers of those people are at risk, too.

Together, they add up to tens of millions of souls – so we don’t want funding for HIV to evaporate. We just want to be able to use more of the money doing sensible things to prevent new infections.

I commend Pisani for telling the politically incorrect truth - culture plays a major role in why some areas of the world are harder hit than others, and it appears that is the case in East Africa. The thing that opened my eyes about the situation in East Africa is how simultaneous promiscuity is a norm among women as well as men. I had a more traditional, male dominated view of the situation, whereby men had multiple simultaneous sex partners while keeping a monogamous wife or girlfriend. It's no wonder that the disease has spread so quickly there.

However I take issue with other aspects of Pisani's approach, specifically her insistence on providing clean needles and condoms without making any attempt to change the behaviors that lead to the spread of the disease in the first place. From a purely medical standpoint this is probably the right thing to do, and I don't think it makes sense to hold disease prevention efforts hostage to behavior modification efforts. But a visit to her website, The Wisdom of Whores offers up evidence that she is actively hostile to policies that attempt to curb risky behaviors, expecially prostitution:

Tobias typifies the hypocrisy about prostitution which riddles the United States. He says he only paid Palfrey’s staff for massages, not for sex. And Palfrey says that to her knowledge her staff only provided massages. She said it in court. He didn’t have to. She was convicted of a number of crimes. He wasn’t. She is dead.

Tobias presided over a programme that aimed to end prostitution in the world. (I am not making that up. Check it out in the Box headed “Violence Against Women and HIV/AIDS”: “The Emergency Plan will also support interventions to eradicate prostitution”.) For a round-up of what people whose livelihoods is to be eradicated think of that, see the links to posts about Palfrey’s death on Bound, Not Gagged. The supporters of this policy argue that the willing buyer, willing seller principle which drives most of American life does not apply in the area of sex. They argue that prostitution is not a victimless crime.

This self-serving moralising, this craven hypocrisy about the trading of sex, is the real crime. It has just claimed it latest victim, in the form of Deborah Jeane Palfrey. May she now find peace.

Maybe in Pisani's ideal world prostitution is not a victimless crime, but in the real world that has yet to yield to Pisani's utopia prostitution has many victims:

WHAT do we know about the woman Gov. Eliot Spitzer allegedly hired as a prostitute? She was the one person he ignored in his apology. What is she going through now? Is she in danger from organized crime because of what she knows? Is anyone offering her legal counsel or alternatives to prostitution?

“I’m here for a purpose,” she said in a conversation with her booking agent after meeting with Governor Spitzer, according to the affidavit of the F.B.I agent who investigated the prostitution ring. “I know what my purpose is. I’m not a ... moron, you know what I mean.”

Her purpose, as a man who knew patiently explained, is “renting” out an organ for 10 minutes. Men rent women through the Internet or by cellphone as if they were renting a car. And now, in response to the news about Governor Spitzer, pundits are wading into the age-old debates over whether prostitution is a victimless crime or whether women are badly hurt in prostitution no matter what they’re paid.

Whose theory is it that prostitution is victimless? It’s the men who buy prostitutes who spew the myths that women choose prostitution, that they get rich, that it’s glamorous and that it turns women on.

But most women in prostitution, including those working for escort services, have been sexually abused as children, studies show. Incest sets young women up for prostitution — by letting them know what they’re worth and what’s expected of them. Other forces that channel women into escort prostitution are economic hardship and racism.

The Emperor’s Club presented itself as an elite escort service. But aside from charging more, it worked like any other prostitution business. The pimps took their 50 percent cut. The Emperor’s Club often required that the women provide sex twice an hour. One woman who was wiretapped indicated that she couldn’t handle that pressure. The ring operated throughout the United States and Europe. The transport of women for prostitution was masked by its description as “travel dates.”

Telephone operators at the Emperor’s Club criticized one of the women for cutting sessions with buyers short so that she could pick up her children at school. “As a general rule,” one said, “girls with children tend to have a little more baggage going on.”

Whether the woman is in a hotel room or on a side street in someone’s car, whether she’s trafficked from New York to Washington or from Mexico to Florida or from the city to the suburbs, the experience of being prostituted causes her immense psychological and physical harm. And it all starts with the buyer.