Book Review

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

N Engl J Med 2009; 360:1367-1368March 26, 2009

Article

The Wisdom of Whores: Bureaucrats, Brothels, and the Business of AIDS
By Elizabeth Pisani. 372 pp. New York, W.W. Norton, 2008. $25.95. ISBN: 978-0-393-06662-3

The Wisdom of Whores is an engaging account of the author's journey through a wide range of positions on the epidemic of human immunodeficiency virus (HIV) infection and AIDS — and a critique of the many things that have gone wrong in the global battle against the epidemic. To her credit, Pisani is candid about her own contributions to many misguided practices, such as the tendency of international agencies — the Joint United Nations Program on HIV/AIDS (UNAIDS), in particular — to “beat up” the numbers of estimated infections to make a case for the use of financial resources that otherwise would never have been committed to a public health issue whose effect is felt most strongly in the developing world.

Pisani is willing to take on what she views as bad science, political correctness, and sacred cows. She freely criticizes accepted truths about HIV, from the inflated estimations of the number of infections to social factors that shape the epidemic. Also under scrutiny are the effectiveness of peer education and the importance of involving people with HIV infection in educational efforts. As alternatives, Pisani offers her own faith in science and an epidemiologist's straightforward understanding of the behavioral facts of the transmission of HIV through highly specific sexual and drug-injecting practices.

Yet her faith in science poses its own problems, since science is by its nature a far more contested terrain than Pisani acknowledges, and the behaviors that open the door for HIV infection are often shaped by many of the social factors she seems to dismiss. It is easy to sympathize with Pisani's frustration at the ways in which the reality of the epidemic has been obscured by the stories that have been told about it, as well as the ways in which these stories have drawn attention from the realities of the sexual and drug-using behaviors that are involved in the transmission of HIV. Yet many of the supposed myths that Pisani dismisses, such as the importance of poverty and inequality between the sexes, have been clearly demonstrated in the literatures of both epidemiology and the social sciences to influence risk behaviors in profound ways in a wide array of social settings.

The greatest strength of The Wisdom of Whores, and a quality that should make this book required reading for anyone who works on HIV and AIDS or in the broad field of global public health, is Pisani's exceptional honesty about the nuts and bolts of surveillance research in public health and about the importance of understanding sexual and drug-using practices if we are to develop prevention and treatment programs that really meet the needs of those who are at risk. This focus on local realities may not be sufficient to answer the apparent political need for a metanarrative or an overarching explanation of the global epidemic, but Pisani reminds her readers that the real work of fighting the epidemic is done in these highly specific trenches of sex and drug use. It is a take-home message that is worth remembering.

Richard G. Parker, Ph.D.
Columbia University Mailman School of Public Health, New York, NY 10032
rgp11@columbia.edu