Stephen Laniel’s Unspecified Bunker

The subtitle certainly captures what this book is about more than Patent Failure’s did. For sheer accuracy of synopsis, maybe the subtitle ought to be “Practical Epidemiology, What We Know About Solving the AIDS Crisis, and How the Politics of International Aid Complicate Matters.” Though Pisani probably wants to sell a copy or two.

The Wisdom of Whores is one of the few books I’ve read that actually lives up to the jacket blurbs. One author describes it as not only a work of science, but also a page-turner. And indeed it is. Pisani holds a Ph.D. in epidemiology, and you can tell from reading The Wisdom of Whores that she has the chops to do serious data analysis. It’s data analysis in the service of a practical end, namely figuring out the most efficient ways to stop AIDS. Pisani has been on the ground interviewing prostitutes and junkies for a couple decades now, so she’s learned a bit about how the disease actually spreads.

Part of the answer is just common sense: HIV spreads when an infected person’s blood comes in contact with an uninfected person’s blood. When heroin users share needles, the risk of HIV’s spreading rises. Unprotected sex is riskier than protected sex. Unlubricated sex is riskier than lubricated sex, because the risk of causing tears is higher. Uncircumcised men are at higher risk than circumcised men. Prostitutes and their johns are at higher risk than non-prostitutes, because they have more partners.

This much should be common sense; the fact that this common sense often doesn’t translate into policy is where the “bureaucrats” in the subtitle come in. The Bush administration and many other nations have changed the conversation: we don’t talk about the actual mechanics of sex and drug use, in part because prostitutes and drug users are considered wicked, and it helps no politicians to aid the wicked. From a public-health perspective, most of our effort ought to be focused on the populations that are most at risk: addicts, gay people, and prostitutes. But that doesn’t sell. What sells is to talk about “neutral” topics: pretend that consumers of prostitution come home to their innocent wives and unwittingly give them the disease, which then spreads to their kids. When you frame the issue as “AIDS hits everyone,” surely you can get votes. Likewise with international aid: if you tell your voters that “poverty and gender disparities” cause AIDS, you can sidestep the icky topics of sex and heroin injection.

Once the money flows, there’s a great risk of corruption and waste. Fortunately, Pisani tells us, there are a lot of people on the receiving end of that money who are really trying to do right by the world’s taxpayers. And there are organizations like the Bill and Melinda Gates Foundation that seem to disburse funds more efficiently and measure programs’ effectiveness better than a lot of governments do. And the governments are learning from their mistakes, in no small part because the epidemiologists on the ground are pushing back on them. Pisani never takes the step that a lot of libertarian fanatics do, namely jumping from the observation that foreign aid can be wasteful to the conclusion that all foreign aid should end. That’s because Pisani isn’t a libertarian fanatic. She’s a hardworking, nose-in-the-details scientist who, like a good disciple of Herb Simon, tries to assume as little as she can before she starts gathering data.

Indeed, the big takeaway from The Wisdom of Whores is that reality is complicated, and that the only way to actually help solve the AIDS epidemic is to dig into the details and be honest about how the disease actually spreads. Don’t let ideology, for instance, blind you to the virtues of free condom distribution. Don’t let ideology stop needle-exchange programs. At the same time, don’t let ideology convince you that needle-exchange programs always work: look at the data first. This book is what happens when a truly scientific worldview merges with the passion of an activist.

Thanks to Alex Tabarrok for recommending this book, and thanks to Chris Blattman for picking up Tabarrok’s recommendation. I heart the web.