The Wisdom of Whores Bureaucrats, Brothels and the

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 CONTENTS

Map
Author’s Note
Acknowledgements

Preface: The Accidental Epidemiologist

1 Cooking Up an Epidemic
2 Landscapes of Desire
3 The Honesty Box
4 The Naked Truth
5 Sacred Cows
6 Articles of Faith
7 HIV Shoots Up
8 Ants in the Sugar-Bowl
9 Full Circle

Notes
Bibliography
Map
 AUTHOR’S NOTE

This is a non-fiction book. The events and facts in it are recorded as

faithfully as my memory and written and electronic records allow. Most
people appear under their real names, or the names by which they
introduced themselves to me. Sometimes this is a first name only (indeed
many people in Indonesia only use one name).
Except where someone was speaking or writing on the public record, I
have tried to seek people’s permission to recount conversations we have
held, or to reproduce their e-mails or written comments. In the few cases
where I have not been able to trace people, I have generally changed their
names.
Most of the documents referred to in the book, including the scientific
references, can be accessed using the links provided on the book’s website:

http://www.wisdomofwhores.com/references

The website also has illustrations, photos and my blog on topics that may be
of interest to readers of this book. Comments are welcomed.

Elizabeth Pisani
London, November 2007
 ACKNOWLEDGEMENTS

The Wisdom of Whores is the product of over a decade of debate, passionate

disagreement, moments of enlightenment, misery and laughter shared with
people in many countries and from many walks of life. Some I am not able
to acknowledge by name, and some whose names I do mention will be
uncomfortable with many of the ideas expressed in the book. I thank them
nonetheless for contributing to my understanding and convictions.
My greatest debt of gratitude is to friends and colleagues in Indonesia–
people who led me through brothels and bureaucracies with patience and
good humour. They include Arizal Ahnaf, Ines Angela, Vidia Darmawi,
Desi, Eris, Mohammad Noor Farid, Frankie, Molly Gingerich, Happy
Hardjo, Naning Iswandono, Saiful Jazan, Balgis Koesnantah, Ratna
Kurniawati, Lina, Ling Ling, Nana, Nancy, Palani Narayanan, Kharisma
Nugroho, Brad Otto, Joy Pollock, Sigit Prihutomo, Chris Purdy, Haikin
Rachmat, Resty, Made Setiawan, Fonny Silfanus, Arwati Soepanto,
Stephen, Lenny Sugiharto, Aang Sutrisna, Bhimanto Suwastoyo, Wayne
Wiebel and Dewa Wirawan. I learned much, too, from other colleagues at
the Indonesian Ministry of Health’s sub-Directorate of HIV/AIDS and at
Statistics Indonesia, as well as at Family Health International’s Indonesian
programme, ASA. Thanks are especially due to Steve Wignall who led
ASA with dedication, compassion and a healthy dose of ribald realism.
Besides making me laugh, Philippe Girault taught me a lot about the
vagaries of fieldwork; Elizabeth Donegan did too. The unflappable Hari
Purnomo was my guru for conflict resolution, and Penny Miller provided a
shining example of the importance of persistence and attention to detail in
turning good ideas into good programmes.
In Beijing, I was lucky to work with the epidemiology division of the
National Centre for HIV/AIDS/STD Control. Thanks to Lu Fan and his
staff, especially Chaganhuar and Wang Liyan who were always willing to
burn the midnight oil in the name of research. I’m also grateful to Cheng
Feng, He Jinglin, Bert Hoffman, Liu Qian, Meiling, Joel Rehnstrom, Wang
Lixue, Wu Zunyou and Zhong Li.
 Some say it is more important to choose a good boss than to choose a
good job; I have been lucky to have both. Jeanine Bardon ran FHI in Asia
with an unbeatable mixture of good humour and steely determination to
build programmes that actually improve lives. She ran an organization
stuffed with wonderful people who taught me many things. Thanks to all of
them, especially Sara Hersey, Nancy Jamieson, Nigoon Jitthai, Mike
Merrigan, Graham Neilsen, Dimitri Prybylski, Boyet Roquero and Ganrawi
Winnithana. Steve Mills and Tobi Saidel were my first friends at FHI; they
taught me about behavioural surveillance and pulled me into the fold, and
for that as well as good friendship I thank them.
I’ve had many good bosses in my wanderings as a consultant: Ties
Boerma, Txema Calleja, Michel Carael, Peter Ghys, Rob Moodie and
Bernhard Schwartlander have all indulged my argumentative nature and
defended my plain prose against UN-creep. Other friends and colleagues in
the AIDS mafia include Andrew Ball, Chris Castle, Kevin De Cock, Don
Des Jarlais, Isabelle de Vincenzi, Geoff Garnett, Robin Gorna, Simon
Gregson, Daniel Halperin, Noerine Kaleeba, John Novak, Wiwat
Peeratapanapokin, Cyril Pervilhac, Deborah Rugg, Swarup Sarkar, Karen
Stanecki, John Stover, Jim Todd, David Wilson, Ray Yip and Basia Zaba. I
have argued stubbornly with most of these people over the years, and with
some I still disagree on many points, but I have always come off the wiser
from our encounters. I’d especially like to thank Tim Brown, who shares
my brain, and Neff Walker, who simply makes the AIDS field a more fun
place to work.
It goes without saying that I thank everyone who appears in the book
for letting me tell their tales. First among equals is David Fox, who has
been in equal parts generous and courageous in allowing me to chronicle an
unhappy episode in our largely happy history.
Several people were kind enough to read and provide detailed
comments on drafts of all or parts of the book. Thanks to Chris Archibald,
Peter Baldwin, Andrew Ball, Jeanine Bardon, Julie Bates, Claire Berlinski,
Karen Broughton, Sophie Campbell, Michel Carael, Adrian Cox, Tim
France, David Gordon, Robin Gorna, John McGlynn, Jack Molyneaux,
Palani Narayanan, Mead Over, Sophie Pinwill, Gray Sattler, Nathalie
Steiwer, Jonathan Swire, Robert Templer and Jack Tenison. Sinead Worrall
brought a whole new perspective to the book. Keith Hansen spent untold
hours pointing out logical fallacies, highlighting clichés and suggesting
improvements in content and structure. He managed to do all of that while
still being a fount of energizing encouragement. Jimmy Whitworth has
entrenched his position as the epidemiologist I most admire by taking the
time to read and comment thoughtfully and amusingly on every chapter of
this book. For that and for a decade of inspiration, many thanks. Chris
Green gets my vote for ‘world’s best activist’. Through careful readings and
forthright comments Chris has tried to keep me both honest and human. I
apologize if I continue to fail on either front. I can only say that the book
has been vastly improved by the contribution of all of these readers.
I’ve been as lucky as it is possible to be as an author. The rather
improbable idea of trying to sell an engaging book about a fatal disease was
enthusiastically swept up by Felicity Bryan. I am indebted to Daphne Park
for introducing us, and to Felicity, George Lucas, Andrew Nurnberg and
their teams for matchmaking me with such wonderful publishers. Sara
Holloway at Granta and Alane Mason at W. W. Norton prodded me kindly
but pointedly in directions that made the book better; they have been a
pleasure to work with. David Graham, Brigid MacLeod, Pru Rowlandson
and Alex Cuadros have also provided good ideas and encouragement.
The Wisdom of Whores exists because Olivia Judson willed it into
being. My debt to her is incalculable. Nicola Bullard provided a thesaurus
while I was writing the book; it was part of a package that included a home
in Bangkok, editorial advice, champagne and friendship; I value all of
these, but especially the last. Havens of encouragement and good cheer
were also provided at critical moments by Jack Tenison and Susannah
Fiennes, by Jonathan Stull and by Lilo Acebal, whose burning enthusiasm
for life has infected me for two decades. Claire Bolderson and Andrew
Wilson have allowed me to be a perpetual squatter in their lives and homes
since the beginning of time. They have housed, fed, entertained, provided
secretarial support, edited, cajoled and uplifted. It seems unlikely that I will
ever be able to thank them adequately. The Damais family in Jakarta have
provided similar sustenance in my adopted home. Terima kasih.
Finally, I’d like to thank my own family. My brother Mark has held my
hand from the start of this project, commenting on proposals and drafts with
the brutal but indispensable honesty that only a sibling can muster.
Annoyingly, he is always right. Mark has been editor, fact-checker and IT
adviser to a sister who works on short deadlines in a different time zone; he
doesn’t get much sleep. He has been a believer in this book even when I
was agnostic-tending-to-atheist. And he’s made it all a lot of fun. I can’t
thank him enough.
My parents met when my father was hitchhiking around the world and
my mother was hitching around Europe. Perhaps not surprising, then, that
they bred into me curiosity, a love of travel and a tendency to talk to
strangers in immigration queues. The result is that they have a largely
absent daughter with a confusing tendency to change countries and
occupations. Yet they have been steadfast in their support for all of my
ventures–from that support I draw strength and happiness. Thank you both.
 PREFACE

The Accidental Epidemiologist

When people ask me what I do for a living, I say, ‘Sex and drugs.’ I used to
say I was an epidemiologist, which is also true. But most people looked
blank. Epi—what? Perhaps something vaguely distasteful to do with skin.
Saying I do sex and drugs saves me explaining that epidemiology is the
study of how diseases spread in a population. It saves me from the social
suicide of admitting that I am a scientist, a glorified statistician, a card-
carrying nerd. And it is a good conversation starter. Everybody has
something to say about sex and drugs.
I’ve discovered that fact in a decade of researching sex and drug
injection around the world. Not an obvious career choice for a nice Catholic
girl, perhaps. In fact, not a career I even knew existed for most of my life. I
became an epidemiologist by accident.
As a child, I followed my corporate exec parents around Europe,
learning cuisines and languages, wandering through flea markets and
billiards halls. When I was fifteen I went to visit a school friend in Hong
Kong. We threaded our way through alleyways slithering with eels in great
plastic tubs, we dodged bow-legged hawkers shuffling between swinging
baskets of lychees, we stuck our tongues out at lollipops of dried terrapins,
crucified on their bamboo sticks. We gyrated with rich kids in flashy
nightclubs, and peeked into tawdry girlie bars. Then we grew bolder,
walking into the girlie bars, ordering beers and chatting to bored sailors,
bored bankers, bored hookers–anyone who would chat. I discovered that
everyone has something interesting to say. I was hooked on Asia, hooked
on nightclubs and girlie bars, hooked on chatting to anyone who would
chat.
I took a degree in Chinese and set off back to Hong Kong, bouncing
into a job as a foreign correspondent with Reuters news agency–about as
fab as it gets for someone who just likes to chat. I reported on liberation
wars and stock market booms and the massacre of hopeful students by
hopeless despots. I visited brothels and orang-utan sanctuaries and military
graveyards. I went to mass with the pope and school with rice farmers in the
paddy fields. I learned some new languages and chatted with thousands of
interesting people, and I got paid for it. I loved it, but I did grow tired of
trying to reduce human experience to 600 words on a two-hour deadline.
Elbowing through the crowds of Hong Kong, New Delhi, Beijing,
Jakarta, I became interested in the politics of population control. Sex and
birth, health and death, priests and condoms, forced vasectomies and
contraceptive ‘safari camps’ (line ’em up on fold-out camp beds and stick
in the coils). The different approaches taken by the mega-nations of Asia
would determine their own future, and perhaps the world’s. There were
days when that seemed more interesting than writing reports on the dollar–
rupiah forex market. On top of that, I’d fallen for a boy who had moved to
London and had a giant, generously rent-free house. So in 1993 I quit the
job, moved to London and signed up for a Masters degree in medical
demography. I wasn’t quite sure what it entailed, but I knew I’d learn some
number-crunching and have luxurious hours in wood-panelled libraries just
thinking. Deadlines be damned.
On the wall outside the wood-panelled library of the London School of
Hygiene and Tropical Medicine danced giant gilded sculptures of
mosquitoes, fleas and tsetse flies–the vectors of the diseases the School
specialised in in the heyday of colonialism. The library itself seemed a relic
from those days, its leather armchairs and leather-bound volumes musty in
the dappled mid-afternoon sunlight. Outside the oasis of the library
swarmed doctors and virologists, lab technicians and statisticians from
every part of the globe. I was moderately numerate–all those stock market
and forex stories–but my exposure to other sciences ground to a halt at
fourteen, when I took my last biology exam. A degree in classical Chinese
and five years in graveyards and paddy fields did not seem like adequate
preparation for a new life as a scientist, I thought, as I picked up the folders
for the two courses required of every student at the school. Statistics and
epidemiology. Epi—what?
In the first lecture, we ‘reviewed’ all the major study types. For
example, in the case-control study you find a group of people with a
disease, and then look for people who are much the same but without the
disease. You compare the two groups to see if they have different risks. It’s
a relatively cheap method, but it doesn’t tell you much about the order in
which things happen. I can’t remember all the examples used in the lecture,
but let’s say you want to look at causes of depression in women. You start
with 600 depressed women, find another 600 who match them in age,
ethnicity and educational status, and then ask them all about their lives.
Let’s say you find out that women who are depressed are six times more
likely not to have had sex in the last year as women who are cheerful. That
means if you’re not having sex you get depressed, right? But hang on,
couldn’t it be that women who are moping around looking miserable don’t
get laid much?
Perhaps you’d be better off with a cohort study. You start off with
several thousand women who are perfectly happy. Then you follow them
over time, recording their behaviours, and see which of them get depressed.
If you find that women who have sex are less likely to become depressed
than women who aren’t getting any, it suggests it is the lack of sex that
causes the depression, not the depression which stops you getting laid. You
can throw out the ‘misery guts’ theory and recommend more good sex as an
intervention to promote mental health.
This may have been a review to most people there, but it was all new to
me. The barrage of ‘facts’ that we see in the newspapers every day took on
a new perspective. Red wine is good for you. No, no, red wine is bad for
you. Well, actually, red wine is good for you but only if you are white, over
sixty, and drink less than 65 millilitres a day. Even for scientists, the stats
are not straightforward. Suddenly, epidemiology began to look interesting.
At the end of that first lecture, the professor asked a question. Why was
there a fourteen-year gap between the first case-control study showing a
strong association between smoking and lung cancer, and the first US
Surgeon General’s report on the dangers of smoking?
Stony silence from the highly educated doctors and technicians in the
room, men and women who were adding a public health qualification to an
existing wealth of medical experience. Maybe this was because it was the
first lecture of the year and people were shy. I was not a doctor. I did not
have an existing wealth of medical experience. I had not had any scientific
education in twenty-five years. But I was not shy. A journalist’s work
depends on a willingness to ask questions of people who are better
informed and more powerful than you. It depends on regarding nothing as
sacred and everything as open to question. I was by far the least qualified of
the 300 or so people in that echoing lecture theatre, but I was full of been-
there-done-that bravado. I stuck up my hand.
‘You’re asking the wrong question,’ I said.
Even I was aware that the air in the lecture theatre had suddenly turned
heavy. Heavy enough to crush the bravado. I blundered on, more doubtful
now.
‘Surely, the key question is: how much money did British American
Tobacco and Philip Morris give to US Senate campaigns in that fourteen-
year interval?’
Immediately, there was a shower of laughter and the air cleared. A
forest of hands shot up, everyone competing to explain in technical terms
that I only partly understood: case-control studies are subject to recall bias,
case-control is not the most appropriate method for looking at causes of
death, what is really needed to confirm the findings is a cohort study that
follows both smokers and non-smokers over time, and and and…
All of these answers were correct, of course. But did that mean the Big
Tobacco answer was wrong?
Science does not exist in a vacuum. It exists in a world of money and
votes, a world of media enquiry and lobbyists, of pharmaceutical
manufacturing and environmental activism and religions and political
ideologies and all the other complexities of human life.
There’s plenty of evidence that a lack of sound science was not the only
thing that dragged down action to discourage smoking. The 1950 study
showed that there were twenty-one times more non-smokers among men
who did not have lung cancer than among men who did have lung cancer. If
that’s hard to follow, it’s because one of the downsides of a case-control
study is that you can’t say A leads to B. So yes, you don’t want to make
public health policy just on the results of that one study. But another 7,000
studies showing similar and stronger results were published before the US
Surgeon General risked the wrath of the rich and powerful tobacco
companies by saying that smoking is bad for you. Well, he didn’t actually
say bad for you. He said ‘a health hazard of sufficient importance to warrant
appropriate remedial action’. Nowhere in the Surgeon General’s 387-page
report did he venture what ‘appropriate remedial action’ might be.1
The report was released during a carefully orchestrated ‘lockin’ of
accredited journalists, held on a Saturday morning. ‘The date chosen was a
Saturday morning to guard against a precipitous reaction on Wall Street,’
according to an official history of the 1964 Surgeon General’s report posted
on the US Centers for Disease Control (CDC) website. Which sounds to me
like an admission that science, case-control study or no, is not the only
thing politicians consider when making decisions about public health.*
The more I thought about it, the more I liked epidemiology. It’s actually
not unlike investigative journalism. You need to ask the right questions of
the right people. You need to record the answers carefully, analyse them
correctly and interpret them sensibly, and in context. And you have to
communicate the results clearly to people who might do something about
them. Journalism (day-to-day news journalism, at any rate) is frustrating
because you don’t always have the time or the tools for thorough analysis.
Epidemiology gives you that. But it seemed to me that epidemiology often
falls at the last hurdle: the communication.
I soon learned that the world of epidemiologists, perhaps like any
professional demi-monde, is deeply divided. On the one side are those who
believe an epidemiologist’s job is to do good science. End of story. Turning
good science into sensible policy is someone else’s job. This camp, which
apparently includes the editors of the scientific journal Epidemiology,
actually believes that it is wicked for epi-nerds to get involved with policy,
because it compromises their scientific neutrality.2
The other camp believes that epidemiology and public health are
inseparable. Public health is not glamorous, and it is not especially well
paid. You work in public health because you want to save a lot of lives. If
you’re going to do that effectively, you can’t stop at the perfect study
design, or even at the publication of your perfect paper in The Lancet or the
New England Journal of Medicine (the dream of epidemiologists in both
camps). An epidemiologist is a scientist, yes, but in the public health camp
that’s not enough. Something that works in the lab but doesn’t work at the
ballot box might be good science, but it is unlikely to get translated into
good public health. So you have to do good science, and then sell good
science.
An idea that kept gnawing at me as I lounged in the library’s leather
armchairs: 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.
 I could have chosen to work on malaria, or dengue fever or maternal
mortality. But if your real interest is the shadowy area where science does
battle with politics, you want to go for the issue that makes politicians most
squeamish. And in the mid-1990s, it seemed that issue was AIDS.
AIDS had first blundered into my consciousness in New York in 1981,
when I was working in a fashion advertising agency for a year before going
to university. Headlines in the Village Voice newspaper screamed about
GRIDS–Gay Related Immune Deficiency Syndrome. At first, the screaming
fell on deaf ears. At the weekends, when I’d sometimes follow the city’s
gay swarms out to the beach at Fire Island, I’d have to tread carefully to
avoid tripping over men entwined with one another in the dunes. Entwined
couples were much more common than condoms on Fire Island in those
days. Within a year, GRIDS had worked its way into New York’s
consciousness. Cafés grew hushed when yet another skeletal figure shuffled
in. Drinks with friends in the city’s gay bars were often interrupted by
volunteers from the Gay Men’s Health Crisis, handing out leaflets and
condoms. By that time drug injectors, haemophiliacs and Haitians had been
added to the list of ‘victims’, and the disease was renamed Acquired
Immunodeficiency Syndrome, or AIDS. The very word AIDS seemed to
strike terror into the hearts of politicians. Ronald Reagan presided over the
emergence of the epidemic in the United States. He witnessed American
and French scientists race to identify the virus that caused it. He saw his old
acting buddy Rock Hudson waste away. But it wasn’t until September 1985
that he managed to say the word AIDS in public.3 Rock Hudson died of
AIDS two weeks later.
The same year, a wasting disease ravaging Uganda which the locals
called ‘Slim’, was identified as AIDS, and every region of the world
reported at least one case. Britain had clocked up 275 cases by the end of
1985. The tabloids were hysterical about ‘Acquired Immoral Deficiency
Syndrome’, and public bodies such as the Blood Transfusion Service were
tiptoeing towards the truth with genteel warnings about the dangers of
‘intimate contact’. When reported cases topped 1,000 in 1987, the
government grew less squeamish. Through every letter-box in the country,
all 23 million of them, fluttered a leaflet giving chapter and verse about
HIV, condoms and safe sex.4
AIDS didn’t make it to the London School of Hygiene’s curriculum
until I was there, in 1994. By then we knew that almost all HIV-infected
adults got their infection when having anal or vaginal sex, or while injecting
drugs with shared needles. Infected blood products could spread the
disease, though that was on the wane. And mothers could pass HIV on to
their infants, in the womb, at birth or while breastfeeding. We knew that in
rich countries, AIDS was a disease of gays and junkies, of prostitutes and
their clients. Those groups were affected in some poorer countries, too. But
in black Africa and the Caribbean, HIV didn’t seem so picky. It seemed
happy to target just about anyone who had sex.
Sex, drugs and plenty of squeamish politicians. AIDS was the disease
for me.
That choice shaped the next ten years of my life. It set me up for a
decade of adventure, discovery, hilarity, hope, disappointment. It allowed
me to explore the guts of worlds I had barely known existed. From
prostitutes, rent boys, pimps and clients I learned about the sex trade.
Addicts, cops and rehab workers taught me about the parallel universe of
drugs. Perhaps the hardest world to find my way around was the AIDS
industry itself, a world where byzantine international bureaucracies fight
turf wars with one another, with pharmaceutical giants, with activist NGOs.
A world where money eclipses truth.
AIDS was not a fashionable subject at the start of my career in public
health, the starting point for this book. It was assuming pride of place as the
number one killer of young adults in more and more countries, but many
people still preferred to close their eyes to it. Our first task was to draw
more attention to the disease, to persuade governments to do something to
prevent their growing HIV epidemics, and to find cash to help them do it. I
immersed myself in these tasks, in the company of a colourful band of
characters crowded into the corridors of an upstart UN agency in Geneva.
We painted glittering portraits of prevention success and thundered about
the tragic consequences of failure. We manhandled estimated infections and
manipulated maps. We did well at drawing attention and finding cash, but
appallingly badly at persuading governments to do the right thing.
Perhaps if we had better information? I threw myself into the task of
helping countries understand their epidemics better. We wrote guidelines
and toolkits, manuals and handbooks, instructing people how to measure
their epidemics better. Then I took the guidelines off to Asia and road-tested
them in Indonesia, in China, in East Timor, in the Philippines. I encountered
a world of women with penises who sell anal sex to men who are