Elizabeth Pisani Interview: How do we spend the money?

This is Part II of an interview with epidemiolgoist Elizabeth Pisani, author of The Wisdom of Whores: Bureaucrats, Brothels, and the Business of AIDS. Here, she talks about where she thinks HIV/AIDS funding is headed — and why in the past we've refused to spend it in ways that actually work. (Read Part 1 of the Pisani interview here.)

Mara Gordon: You spend a good section of your book debunking the "family values first, science-based facts second" global health policies of the Bush Administration. Where do you hope American HIV/AIDS funding -- and money for global health in general -- will be headed under the Obama administration? Where do you think it is actually headed?

Elizabeth Pisani: I think it is probably headed in the right direction. A lot of very smart people have had to keep a pretty low profile in US institutions such as CDC, USAID and NIH for some time now. But they do know what needs to be done -- clean needles for drug users, constructive work with people in the sex trade, effective prevention programmes for men in prison, full information and a very broad range of service options for people who are considering sex outside of the monogamous-from-marriage-as- virgins ideal so beloved of preachers in sermons if not always in practice. Those are some of the things that need to be done now, but as the data change, the needs will change, too

MG: Your book focuses on HIV/AIDS prevention and treatment. In my experience working in public health in sub-Saharan Africa, earmarked aid money specifically for HIV/AIDS actually weakens health systems; disease-specific funding ignores the way that all health problems, inevitably, are interrelated and intertwined. Do you agree?

EP: Ooooh, this is a big, furious debate right now. Perhaps surprisingly, I don't have very strong views – the evidence goes both ways. On the one hand, smart governments dedicated to the welfare of their people can use disease-specific funding to build up systems that they can then subvert for use with other diseases and even other development problems. On the other hand, opportunistic, inefficient or corrupt governments can suck at the teat of disease-specific funding very easily, while failing to do anything to address the many other problems that you rightly point out are likely to be linked to that specific disease. (Now, if a government has allowed a fatal, preventable disease to infect a quarter of adults without taking any of the culturally-hard-but-necessary steps it could have taken to prevent it, do you think it is more likely to fall into the smart category or the corrupt category?)

Sometimes, the only way you can get funding is to take disease-specific funding. If you use it right, that's fine by me. That includes using whatever proportion of it you do spend on the disease in question effectively. But I think it is particularly difficult to use it right (and particularly likely to undermine health systems) where the disease you are taking funding for exists only in sub-populations that no-one gives a damn about. And that's the truth of it in most countries outside sub-Saharan Africa.

MG: Another interesting tension I observed in your book relates to the way HIV prevention programs target different populations. In Thailand, we should work with sex workers. In South Africa, truckers. In Uganda, the successful "zero grazing" partner-reduction campaign argued that everyone in Ugandan society is affected by HIV/AIDS. When are population-specific strategies successful, and when are they not?

EP: Epidemiologically, population-specific strategies are successful when a high proportion of all new cases are being generated by defined behaviours in a
certain sub-population. If six houses on your block are on fire and there are no fires anywhere else in town, do you want to bring all the firetrucks to your block, or do you want them to go around filling a bucket in every household in town, because, well, you know, every house could be at risk of burning down? In most countries, HIV is a fire that tends to burn in two or three blocks. In Eastern Europe and parts of Asia and southern Europe, HIV is spread mostly between people shooting up drugs together. In much of the Americas (including the US), much of Europe and Australasia, it's spread mostly between men having anal sex with one another. In East and Southern Africa, it is spread largely in sex between (often younger, often unmarried) women, and older men. A far, far higher proportion of the population in any country in East and Southern Africa fit that risk profile than fit the risk profiles for gay men or drug inejctors in other regions, so it is in those countries that you have to spread your firetrucks more widely. Obviously you're going to need more firetrucks, too.

[Photo credit: hdptcar]