The Wisdom of Whores

Most people spend long summer evenings in Paris strolling arm in arm around the boulevards, sitting in cafes or lolling in parks. I spent this weekend in the sewers. Am I odd in finding drains a sexy subject? Perhaps. But they’re my number one candidate for a Song of Contagion.

I’m lobbying for a diarrhoea story that starts in 1830 and tells the story of poo-related deaths in London and Calcutta. The British and the Indian music will start off at the same volume because back then, diarrhoea was killing roughly the same proportion of the population in those cities. Then in the 1850s the British music gets deafening — that was the Big Stink and the cholera epidemic that followed. This rattles the Victorians into action, and they start to build drains — represented by the introduction of a didgeridoo as a bass-line to the British music (I’m hoping for a dij because it both looks and sounds like a drain…) As a result, diarrhoea deaths in London plummet. While the dij bass-line carries on, the rest of the British music gets quieter and falls silent. The Indian music, on the other hand, never gets a bass-line. Neither the colonial government nor the many subsequent Indian governments have invested sufficiently in basic sanitation, and tens of thousands of children continue to die of diarrhoea in Indian cities to this day.

Whether this story gets selected or not is up to Tony Haynes and his song-writers and musicians in the Grand Union Orchestra. But it is also up to you, and whether you have better ideas about which diseases would best illustrate the different social, political and physical forces that shape our perception of the importance of a specific illness. In our current thinking, the list of parameters which affect our perception of disease fall into four categories. They look like this:

Other candidate diseases to be turned into a great musical stage show include HIV, shellshock-to-post-traumatic-stress, Zika-vs-dengue and rhuematism-vs-erectile-dysfunction. If you’ve got ideas for diseases that would make a good, data-driven song, e-mail us at info@songofcontagion.com. Or if you are in Oxford on June 20th, come to the Wig and Pen between 17.30 and 19.30 to share a pint and your ideas. If you’re in London on Monday July 11th 2016, Elizabeth is offering beer, pizza and a chance to get your disease on stage to anyone who wants to come along for an evening of brain-storm-draining. E-mail info@songofcontagion.com for time and place.

I’ve just emerged from three days buried in a bunker at the Geneva Health Forum, which focuses on health in lower income countries. There was a great cartoonist, but otherwise it was all quite po-faced: power-point presentations, incomprehensible posters and much thanking of sponsors. LOTS of rather earnest, mostly white people suffered from the Public Health Fallacy: the idea that if only they had the (technical) evidence, all governments would do the best thing for their poorest and most neglected. Despite all of the (historical, political, social) evidence (.pdf) that the poorest and most neglected mostly get, well, neglected by those that govern them.

I propose adding this to the evidence base: po-faced conferences with power point presentations to an audience that has seen them all before do not generate new ideas about inequality in health. And I propose trying something different: let’s put the technical evidence up against the historical, political and social evidence in a piece of music, and see what gets drowned out.

Does that sound crazy? Maybe. Will it change the world? Of course not. Will it allow us to think a bit more creatively than another powerpoint presentation in a bunker conference? Probably. Will it be a lot of fun? Certainly!

Come along tomorrow, Saturday April 23, and add your voice to the project, which we’re calling Song of Contagion. (It’s supported by the Wellcome Trust, and most of what they support turns out pretty well.) We’re meeting in Hackney, East London, to begin to decide which diseases to songify, and what, besides the technical evidence, we should be adding to the musical mix. The fact that the Minister of Health’s wife owns a Pharma company, maybe? We didn’t hear THAT at the Geneva Health Forum…

If you’re wondering about the illustration, I was in Geneva to discuss with colleagues how we might turn the asteroid field of public health data sharing into a nice, tidy solar system. Right now, if you played public health data sharing in music, it would sound so cacophonous that many people would just switch it off. To turn it into a symphony, we need to appoint someone to act as conductor, and start investing in more players in the orchestra. But that’s a whole separate post…

Today is World Health Day. Judging from what’s in the Song of Contagion Twitter stream (@songfocontagion), this is above all an opportunity for a lot of lobbyists and marketing specialists to promote their specific cause. Greenpeace has been quite active, because of course you can always make a health issue out of the environment.

There’s quite a bit from the Indian government, a lot of it focusing on diabetes (the prevalence of which, we will learn from The Lancet tonight, has more than doubled in India since 1980). But there are also Indian companies trying to convince us that ghee, or clarified butter, is good for us after all.

We’ve got single-disease NGOs all clamouring for our attention to “their” disease, often with recourse to statistics. This from the Mental Health Foundation for example:

Finally, you’ve got marketers of fads and gizmos, all capitalising on World Health Day.

All of this is part of the clamour that leads to really important decisions about what research gets done and which interventions get funded. (Oddly, I’ve seen little today from Big Pharma, who I thought would be all over Twitter — maybe they are promoting their wares through the NGOs and foundations they fund?) If you want to help us make sense of how much influence initiatives such as World Health Day really have, then turn the results into music, please join us on the Song of Contagion project. Details here of our April 23rd launch workshop — which will discuss how priorities are set in global health.

Yesterday, during a visit to the thought-provoking Museum of the Mind, on the premises of the Bethlem hospital (still active but now renamed), I was reminded both how far we have come in the treatment of mental illness since the ‘Bedlam madhouse’ was first opened, and how far there is still to go.

At the entrance to the new museum stand the two statues which sat over the gates to the old hospital from 1676 to 1815: “Raving Madness” (pitcures above) and “Melancholy”.
When they were carved, these just about covered the range of diagnoses for mental illness. Many centuries later, we have a far better understanding of all the ways in which the mind can be ‘broken’, as well as the different manifestations of mental illness. Today, for example, is World Autism Awareness Day; although first coined by a Swiss psychiatrist in 1911, the word autism wasn’t used in its current sense until the 1940s, long after the building that houses the latest iteration of the Bethlem Hospital was built.

It made me wonder: how has the divvying up of mental illness into infinitesimally narrow diagnoses affected those who live with it? Have some types of mental illness or their manifestations become more ‘acceptable’ than others? Does that affect how much research we do into them, or how much treatment is available?

These are the sorts of questions we’ll be discussing at Song of Contagion as we try to turn different diseases and illnesses into music. Please come and join us at the launch workshop on April 23rd, 2016, or any time along our musical journey.

As subscribers know, I’ve more or less dropped off the HIV map in recent years. That’s in part because there are so many other interesting health conditions out there to think about. And that keeps me thinking about why some conditions are more fashionable than others, why some things that affect very few people (such as testicular cancer) get quite a bit of research money while others — dreary things like rheumatism that make life miserable for tens of millions — get hardly any cash at all. You can show PowerPoint slides about the mismatch until the cows come home, and no-one seems to take much notice. But what if we could communicate the inequities in global health in other ways. Through music, for example?

Now, with support from the Wellcome Trust we’ve got a chance to do just that. In a project called Song of Contagion, I’ll be working with fabulous, multi-ethnic East London based Grand Union Orchestra to develop a show which plays music in variations, so that you can “hear” the difference between health conditions — how much death and misery they cause, who’s affected by them, how much press coverage they get, and how much money. Eventually, we’ll put on a show at the iconic Hackney Empire. But to start off, I need your help. This isn’t a Kickstarter — it’s completely free! We just want people who are interested in the politics of health and disease, or making great music, or both to show up to fun, one-day workshops in London. The first, to discuss what should go in to the show, will be on Saturday April 23rd, 2016. The show will be shaped by your input. You get to choose the diseases that will be “played” and the factors that influence funding, which will be mapped on to music parameters such as volume, tempo and pitch. Will HIV sound loud and screechy? It’s up to you.

Please, join us, and tell your mates, via Twitter or Facebook.

Adult Intensive care ward at the Hospital for Tropical Diseases, Ho Chi Minh City, ©Chau Doan/Getty Images

Recently, I have spent a good deal of time working on the issue of anti-microbial resistance. I was set on this path by the discovery, nearly a decade ago now, that the drugs we were using to treat STIs among sex workers in Indonesia didn’t work. Sending the bugs off for resistance testing, we found that 100% were resistant to one of the medicines recommended by national guidelines, and over 60% were resistant to a second medicine. Despite that, we went on treating people with these largely useless drugs for the FOUR YEARS that it took to change Indonesia’s national guidelines for STI treatment. Welcome to the fiercely political world of drug procurement and prescription (and the ethically appalling behaviour it promotes).

Recently, I’ve been focusing on one of the most political and (therefore) most neglected drivers of drug-resistant infections: poor quality medicines. Essentially, the pressure to increase access to drugs for everyone who needs them (a good thing) has created all kinds of loopholes that allow lazy, unscrupulous and criminal manufacturers of very bad drugs to prosper without proper oversight. Every time someone tries to raise the issue of bad quality generics, the companies that make them, the governments of countries where they are made, and a number of very shouty NGOs simply accuse the critics of being in bed with Big Pharma. There the conversation ends. But it is simply not true that access to bad drugs is better than no drugs at all, because bad drugs breed resistant bugs, and then even the “good” drugs are, well, no good.

There’s a very detailed report on the interaction between drug quality and antimicrobial resistance over at my day-job site. But for a shorter and better read on the subject, check out Why we are losing the war on bugs over at Prospect Magazine. (January 21, 2016). An archived .pdf of the article is available here

The BBC welcomes the Year of the Horse. Sort of.

Last week I found myself at the House of Lords in London, discussing what the BBC World Service means to the world. The World Service stands for accuracy in reporting, a lot of very clever people said, it represents fairness and impartiality, it tells it like it is. So I was thrilled to see that the Beeb welcomed in the Chinese New Year with a celebration of Whores.

Other signs that it might be a good year: this peculiarly sensible opinion piece about sex trafficking hysteria from Kate Mogulescu of the Trafficking Victims Advocacy Project. I have to say that when I read the headline on the op-ed page of the New York Times on Saturday:

The Super Bowl and Sex Trafficking

my heart rather sank. I always find those “where there are sports fans, there will be sex-slavers” stories particularly hard to swallow at the breakfast table. This piece, though, points out not just the data-free hysteria-by-rote that we’ve become accustomed to, but the harm that it does to sex workers in general, and trafficked sex workers in particular.

新暗 娼 的 年 快乐！

Thanks to The Independent and Don Dickerson.

In late 2011, epidemiologist, writer and adventurer Elizabeth Pisani granted herself a sabbatical from the day job and set off to rediscover Indonesia, a country she has wandered, loved and been baffled by for decades.

The journey forms the backbone of a book (and a multimedia BookPlus), which includes also reflections on her earlier incarnations in Indonesia. The first of these was as a foreign correspondent for Reuters in the late 1980s and early 1990s. Ten years later she was back in the very different guise of epidemiologist, helping the Ministry of Health better understand Indonesia’s HIV epidemic. That work contributed to her first book, The Wisdom of Whores, published in 2008.

The new book that will emerge in June 2014 will be called Indonesia Etc: Exploring the Improbable Nation. It will be published in the UK by Granta, in the US by WW Norton and in Indonesia by Godown, an imprint of always-inspiring Lontar.

The title Indonesia Etc is taken from Indonesia’s declaration of independence, which reads, in full:

We the People of Indonesia declare the independence of the Republic of Indonesia. The details of the transfer of power etc. will be worked out as soon as possible.

As Indonesia gears up for the 2014 elections, it is still working on its political “etc”. “Democracy by trial and error” was how one retired company head described it to me with a mirthless laugh. How far will decentralisation go? Will independent candidates and local parties be allowed? Much is still up for discussion or re-discussion. And yet the improbable nation muddles along remarkably well for such a young country. Re-reading Abraham Lincoln’s Gettysburg Address today, I was reminded that the United States, at a similar stage after its own declaration of independence, still had a bloody civil war ahead of it.

Though it looked touch-and-go for a few years at the start of this century, few people now expect Indonesia to face that kind of chaos in any of its vast territory (except, perhaps, Tanah Papua).

“Indonesia Etc. – Exploring the Improbable Land” is a vibrant mix of travelogue, history, cultural observation and analysis.

The blurb:
One in 30 of the people on this planet is Indonesian. The 13,000 islands of their homeland, scattered along the equator, stretch the distance from London to Tehran, and the residents of the capital, Jakarta, tweet more than those of any other city on the planet. By any standard, Indonesia is a global hub, one of the most dynamic and diverse countries of the 21st century. But you don’t have to look far from metropolitan Jakarta to find poverty, superstition, ancient rituals and black magic. Travelling from volcanoes and jungles to reefs and snowy peaks, investigative reporter Elizabeth Pisani sets out to capture the real Indonesia. On the way she meets the Sultan of Jogjakarta, a former presidential candidate who keeps a posse of albino dwarfs in his court, visits one of the largest red light districts in Asia, joins protesters trying to ban Lady Gaga from their homeland, and takes tea with a recently deceased grandmother. Written with Pisani’s trademark wit and brio, this is an entertaining and indispensable guide to a fascinating country we can’t afford not to know more about.

It’s not often that proper reporters put their own reaction to the story they are working on front and centre, but it can be revealing. Have a listen to this wonderful From Our Own Correspondent from gay BBC journalist Paul Henley reporting from the frontlines of Russian homophobia.

Without whining, Henley gives a wonderful flavour of what it is to be hated by people who don’t even know that they hate you. For me, the encouraging thing about this story is that the wall of hostility that Henley is obliged to bang his head against in Russia is new to him. Had he been born even 30 years earlier in the UK (and maybe still now in many parts of the United States) the blanket of homophobia would be woven, consciously or not, willingly or not, in to his life and his soul.

It’s not at all encouraging if you are Russian, of course, or Ugandan, or from one of the many other countries where self-appointed moralists like to stick their prurient noses into other people’s bedrooms. But the fact that Henley can broadcast his sexuality to the 180 million people who listen to the BBC World Service and make many of us feel proud of him means that in some countries, at least, we have come a very long way in the right direction.

The good side of homophobia is the vanishing side.

The always provocative Unspun asks how it is that Indonesia’s minister of health is shocked at the country’s HIV prevention failure. It’s a good question, most especially since before becoming minister of health just a few months ago, Nafsiah Mboi spent six years at the helm of the National AIDS Commission.

The failure was highlighted in the new UNAIDS report on the state of the epidemic. They estimate that the rate of new HIV infections in 2011 was more than 25% higher in Indonesia than it had been a decade earlier. That raises some questions for me: is an increase of more than 25% in HIV incidence (i.e. new infections) over 10 years really so shocking? Is the rate of new infections in Indonesia still increasing today? How do we know?

1) How shocking is an increase of 25%?
It rather depends on what the original rate was. The fact is, Indonesia had virtually no HIV epidemic in 2001, except in drug injectors and waria sex workers. In other words, the baseline rate of new infections in the largest risk populations (female and male sex workers, their regular clients, and gay men) was extremely low. If you go from four new cases a year to five new cases a year you increase by 25% but add only one new infection. If a high prevalence country goes from 11,000 incident cases to 10,000 cases, it has decreased by nine percent but added 1000 new cases. Which is the bigger prevention failure? I’m not saying that HIV prevention in Indonesia is a great success story; quite the reverse (see below). I’m just reminding people to beware of relative measures.

2) and 3) Is the rate of new infections in Indonesia still increasing now? How do we know?
The fact is, we don’t. Indonesia, which in the early 2000s built up quite a strong surveillance system, has seen that system break down rather badly, in part because of the effects of decentralisation and in-fighting between government departments which means that people who should be running the system are busy squabbling over project funding, and in part because of the small-mindedness of some of the donor-funded NGOs, who cared more about measuring their own little efforts and sucking up to their own pet partners in government than about supporting strong and transparent national systems. We can’t measure new infections directly, so incidence estimates are based on models that use information about overall infection rates (prevalence) from several years for several different population groups, together with information on risk behaviour, in some case. I’m frankly surprised that UNAIDS even published an incidence estimate for Indonesia, given the shockingly poor quality of the data available in the last 5 years. I note that they shied away from giving estimates for many of the other large countries with similarly diverse epidemics and patchy data: Brazil, China and Russia.

That HIV prevention failed in Indonesia is indisputable. The failure was totally unnecessary, but sadly inevitable given the choices the country and its “development partners” made. When infection rates were still low we measured very high levels of risk behaviour in key groups. We did very little about it, and what we did was more often driven by institutional needs and development fashion than by the needs of the people at risk. We kept measuring risk and infection and saw that risk was not falling and infection was rising. We spent lots of time and energy getting more money, then threw the money at the same failed approaches (including, in the most iniquitous example, treating people’s STIs with drugs we knew didn’t work because the Ministry of Health, the WHO, the drug companies and their various cronies couldn’t get their shit together to change the outdated national guidelines on treatment).

If what data we have are to be even remotely believed, there does appear to have been some success reducing new infection rates among drug injectors. But by 2009, three years into Nafsiah Mboi’s tenure as head of the KPA, Indonesia had sucked 60 million dollars into its HIV coffers, for that year alone. How much of that was spent on HIV prevention for gay men, a sizeable group in whom infection rates had rocketed from under 3% in Jakarta when I did the first study in 2002 to over 8% in 2007? A princely US$ 23,000. It’s not at all shocking that HIV prevention doesn’t work if you are simply not doing it. Or if you are doing the kind of thing Indonesia is mostly doing, pictured above. The poster reads: “Don’t ruin your life for just a moment’s pleasure. HIV/AIDS. You can get it, you can prevent it.” Does it tell you HOW you can get it, HOW you can prevent it? No. And there are even worse examples out there.

Here’s something that I found shocking: UNAIDS chief Michel Sidebe was in Jakarta just a couple of months ago. What did he talk about? Not the gay men, junkies, waria, rent boys and clients of hookers that make up four fifths of the Indonesian epidemic (the majority of other cases being in female sex wokers). Or at least not according to newspaper reports of his visit. No, he talked about the importance of protecting innocent women and babies through sexual education for young people, most of whom are at practically zero risk. (Reminder, you can’t get HIV by having sex, even unprotected sex. You can only get HIV by having unprotected sex with an infected person. As long as they stay away from the trade, most young heterosexuals in Indonesia can have as much sex as they like without risk of HIV infection.)

The highest UN official for HIV comes to Indonesia and stresses the importance of prevention for people who are not at risk, and Ibu Naf wonders why infections continue to rise in the groups that are at risk. Please deh! Someone should write a book about this.

Oh wait, I already did….

Note: This is a cross-post from Elizabeth’s Indonesia blog, tales and observations from my current project. Though I planned to be back in the public health business round about now (November 2012), Indonesia has rather swallowed me up and I won’t be back in the day job for a while yet.

I learned this today from a subscriber to the Asian gay website Fridae, who was irritated by my tone in an post-midnight interview with Ng Yi-Sheng, a fabulous Singaporean poet. I am more than willing to accept that being snarky about other people’s sex lives is an irritant. But I’m not sure how it leads to this:

I’ve never had to fumble lubily with a condom packet, huh? The potential assumptions about my behaviour are manifold. Here are some that occur to me:

1) I never use condoms
1a) because I’m a slob
1b) because I don’t have sex with people who have penises
1c) because I don’t have sex.

2) I never use lube
2a) because girls (I?) don’t need it even when they are in their late 40s
2b) because girls (I?) never have anal sex
2c) because I don’t have sex

3) Uniquely on the planet, I can always tell which side of a condom is out
(I refer Mr. Tereisias to p 208 of The Wisdom of Whores)

4) I don’t drink alcohol or take party drugs

All of these assumptions are wounding to the core. But it gets worse: not only do I not have boozy but protected sex with boys who might like lube: I NEVER WILL!

Perhaps I’m being over-sensitive because I’ve just put another birthday on the clock, but I’m crushed. Truly crushed. And bent on the sweet vengeance that comes with proving someone wrong on every count…

On a quick sabbatical from my sabbatical, I’ve dipped back to London for the month of July. How better to spend my first Saturday night than at my local theatre, watching a show called “Bitch! Dyke! Faghag! Whore!”.

The night before, I indulged in the things I’ve missed most over the last nine months — good wine and pork products — under giant banners reading:
LESBIAN
Mayor of London
and
TRANS
Mayor of London

in Trafalgar Square. London’s most public square was getting all gussied up for Satruday’s Pride parade. We take it for granted now that boys dressed in black latex and pink feather boas kiss in public, but in a show that’s just turned 20 Penny Arcade, aka Susana Ventura, reminds us how very hard fought a victory that was. She and I differ, perhaps, on how that past should shape the behaviour of later generations, those who have mercifully not been condemned to live in closets and funeral parlours, but differences are what good drama are all about. And Penny reminds us, too, (particularly in a funny opening riff on the current “controlled for gain” morass) of how far we still have to go. All wrapped around some of the most heart-stopping pole dancing you’ll see outside of the Olympic gymnastics ring.

Have a pint or two and go see for yourself.

I’m nearing the end of the first (nine-month long) leg of my Indonesian Odyssey and I don’t feel much closer to understanding the heart of this torturously complicated but endlessly fascinating nation. I’ve done my best to try and sum up some of my thoughts in the June issue of Prospect, one of UK’s more intelligent monthly magazines.

For what they are worth, you can now read my reflections on culture, corruption and corpses on Prospect online. And no, Oliver, I don’t think it is at a crossroads…

[Crosspost from Portrait Indonesia]

As part of the Makassar Writers’ Festival, I’ve been asked to give a talk about HIV in Indonesia at the faculty of public health at Hasanuddin University. I’m reluctant. I’ve been wandering Indonesia without any thought of focusing on HIV for over eight months now. In that time I’ve met a surprising number of widows, orphans and middle-aged couples who have lost a child. Only one of those deaths has been HIV related. The rest are all in traffic accidents, mostly involving motorbikes.

That’s not entirely surprising. Bike ownership in Indonesia is booming, with 8.1 million new motorcycles crowding on to the country’s shockingly bad (and already crowded) roads last year. It’s perfectly common to see primary school kids driving motorbikes; it’s very rare to see a primary school kid in a helmet. And the industry is not exactly doing a lot to promote norms of safe driving. Here’s how Suzuki was pimping its new (quite girly, automatic transmission) model in Bau Bau, Southeast Sulawesi, last weekend.

Reporting of road accident related deaths is even worse than reporting of AIDS deaths in Indonesia. But working on best estimates, death contracted on the roads far outstrips death contracted in bed or while shooting up. Some 32,000 people died because of road accidents in Indonesia last year alone, a quarter of them teen-aged boys, and 60% of them on motorbikes. Ten times as many were injured badly enough to alter their daily lives. That compares with just over 5,000 Indonesians reported as having died of AIDS, ever. Let me repeat that. Over 30,000 road deaths a year, versus 5,000 or so AIDS deaths over the last 25 years. And yet Indonesia spent US$ 69.2 million preventing HIV infections and AIDS deaths last year, 60% of it taken out of the wallets of taxpayers in other countries, much of it spent very badly indeed. Indonesia does have a national road safety action plan, but, according to the Director of Road Safety in the Ministry of Transport, it has no dedicated budget to cut death on the roads. If I didn’t know better, I might console myself that HIV is not much of a problem in Indonesia precisely because of the prevention spending. Sadly, that’s not true. I also recognise, of course, that death tolls are not the only basis on which to make public health decisions. But it doesn’t take a very sophisticated observer to see that HIV programmes in Indonesia are grossly over-financed relative to other important killers and maimers, notably road death. (Then there’s smoking, but that’s a whole nother post…)

It doesn’t seem like this problem is likely to evaporate. Though the motorbike industry is wringing its hands over the effect that a perfectly sensible new restriction on credit will have, I’m not seeing it in the field. The Suzuki mob were offering new bikes for a downpayment of just 350,000 rupiah (about US$ 38.00). If that meets the 25% deposit requirement of the regulations, which came into effect this month, then it is a VERY good value bike, despite being girly. Even by the most pessimistic estimates, there will probably be another 6.5 million bikes and over 800,000 more cars on the roads by the end of this year compared with the start. Remove the several thousand that will be reduce to scrap by crashes, and its still a huge net addition.

For an idea of how far Indonesia has to go in making its roads safe, check out this presentation by Eric Howard. There’s lots he doesn’t mention — the political incentives to finance the building of sub-standard roads, the fact that Indonesians think road safety campaigns are just another way for policemen to extract bribes — but there are some priceless photos that show just why for most Indonesians, it’s probably far more dangerous to make your way to work or to school than it is to have sex.

[Cross-post from Elizabeth’s current project, PortraitIndonesia.]

© Kompas/HANDINING

Wednesday was a sad day for Indonesia, and for me. It marked the death of Endang Sedyaningsih, who encompassed what is best in the women everywhere: courage, determination, integrity, compassion and humility. It is a rare combination at the best of times; in the Indonesian cabinet, where Endang held the position of Minister of Health, these qualities are nothing short of exceptional.

I’ve been pretty rude about Indonesian doctors lately. Endang counts among the “several smart friends who were once great doctors”. Unlike many ministers in Indonesia, she knew her territory inside out. For three years, she worked as head of a rural health centre in Nusa Tengarra Timur, the poorest province in Indonesia. She gave up doctoring in favour of public health and research, a choice that I predictably enough applaud, not least because a lot of her research was among sex workers and other marginalised groups. Indeed her thesis at Harvard centred on the lives of the women who sold sex in Kramat Tunggak, Jakarta’s largest red light district. She argued for improving health services for the women that worked there. Jakarta Governor Sutiyoso, seeking to burnish his credentials with Moslem voters, responded by bulldozing the area and building a gopping mosque and Islamic centre in its place. When Kramat Tunggat was closed in 1999, HIV prevalence among brothel and street-based sex workers in north Jakarta was 0.4 percent. Since the rise of the mosque and the dispersion of the sex trade, it has risen to 10.5 percent.

Endang was fearless both physically (not many of my colleagues were prepared, as she was, to brave the Jakarta traffic on the back of my motorbike…) and politically. During the reign of her controversial predecessor, Siti Fadilah Supari, Endang had to put up with a lot of flack because the national health research institute she headed cooperated closely with foreign researchers in trying to develop vaccines against bird flu, which has a higher case fatality rate in Indonesia than in any other country. For Siti, this cooperation amounted to collaboration with the enemy. Her book “It’s Time for the World to Change! God’s Hand Behind the Bird Flu Virus” is actually more about the hand of the CIA behind the virus – a mish-mash of conspiracy theories which were such an embarrassment to the Indonesian government that the book was eventually pulled from bookshops.

Leading the research programme for the Ministry of Health, Endang kept her head down and got on with her work. In her eyes, finding a vaccine that could protect millions of her fellow countrymen from a strain of flu that killed eight out of 10 of those infected was more important than whipping up populist anti-Americanism to score cheap political wins. When she was appointed health minister in Indonesian president Susilo Bambang Yuduhyono’s second cabinet, the press showered her with nonsense about being a CIA plant. Again, she kept her head down and got on with her work, trying especially to improve services in the far-flung corners of the nation so often overlooked by those trapped in the political spider’s web of Jakarta.

Endang was an Indonesian nationalist in the truest sense of the word: not a knee-jerk Xenophobe, but someone who consolidated learning, skills and relationships acquired around the world and used them in the service of the men, women and transgenders of the Indonesia she loved so much. I am angry that she was taken from us by lung cancer at the age of only 57, but am proud to have called her a friend.

Spain. With the possible exception of the one I’m trailing around now, it’s my favourite country on earth. For many reasons, including a sense of social solidarity and the fantastic pragmatism of Spanish women. Madrid’s sex workers have been displaying both, refusing to sell sex to bankers until those blood-suckers start lending money to the small businesses that need it most.

I’m particularly thrilled with the timing of the strike; it seems somehow fitting that it coincides with the publication in Spanish of La Sabiduria de las Putas. Four years after The Wisdom of Whores was first published in English, Sexto Piso is publishing it in Spanish. This makes me happy in part because my favourite bookshop in the world, Madrid’s Panta Rhei, will now have a Spanish version to put on their shelves (though my humble tale of sex and taxation will feel dowdy among the fabulous art and design books that are Panta’s stock in trade).

For a brief moment, I worried that Sabiduria would seem very dated. For better or for worse (for worse, I guess) and despite the change in regime in Washington and a growing recognition that countries need to “Know their epidemic”, there’s an awful lot in the book that is as relevant today as when I first drafted it six years ago.

Sabiduria is being published mainly because of the determination of Javier Rio Navarro, a Basque epidemiologist who, with the stubbornness of his tribe, takes on tasks that would make Hercules faint. He established Bilbao’s first safe injecting room for drug users, for example. And he translated The Wisdom of Whores. He’s now banging his head against various (hard) walls in Central America, trying in particular to get mental health services to people who are constantly beaten up or beaten down by their street-based lifestyle. (pdf) I thank him with all my heart for making La Sabiduria possible.

A statue outside a health centre in Enarotali, in Indonesian Papua

[Note: I’m still on sabbatical. But even on sabbatical, one sometimes thinks about sex… For reflections on democracy, corruption and other dirty subjects, see my other blog, from which this is a cross-post.]

Reading the newspapers in cities across Papua, Indonesia’s easternmost province, I cannot help but notice the full-colour ads for penis extensions. In only half an hour, with no invasive anything, men can see their organs grow, thicken, harden, for ever. The ads are explicit about the results, down to the last half centimetre; clients can choose both the length and girth of their organ, up to 20 cm by 6 cm (the more modest promise diameters of just 5.5). All of this with just some magic oil and a few prayers, guaranteed free of side effects. The “Specialists in Vital Organs” promise services for women, too, tightening up our fannies “until you are like a maiden again”. And for both sexes, they will pray away our sexually transmitted infections.

Why the obsession with sex organs, and why especially in Papua? Are people encouraged by the blatantly erotic sculptures that are common in these parts? Do migrants from other parts of Indonesia feel inadequate on arrival in Papua, or do they feel the magic will be especially potent in the nether regions of the nation? And isn’t it mildly ironic that all of the people offering their dick-swelling charms claim to be from Banten in western Java, where mystics sometimes break their fasts by eating light-bulbs? They offer other mystical services too: tying down your spouse, implanting a protective aura, ensuring you get promoted or elected. But most of their force is expended on delivering: “What other people only promise, we prove with results that are Large and Long”.

It turns out that the penis obsession is not, in fact, confined to the tens of thousands of immigrants from the rest of Indonesia who have been sucked east by Papua’s booming economy. I learned this when I asked a Papuan nurse in one of the province’s largest hospitals what brought men to outpatient services. Three things, he said: injuries resulting from violent fights, injuries resulting from traffic accidents, and prison. Prison? Do people get sick in prison? “No, that’s the penis stuff.” Prisoners, Papuans and others, are operating on one another’s members — inserting ball bearings and biro parts, threading hair through the urethra. A doctor friend who ran an STI clinic in Papua for many years says he saw a lot of penises embellished with horse hair, but the nurse said since that’s in short supply in prison people weave ornaments from their own locks. Not surprisingly, many of these go septic, hence the hospital visits.

My doctor friend blames the porn industry for the penis-plumping craze. “People watch these porn films where everyone has a giant dick, and they begin to think that that’s the norm.” Certainly porn films are enough of a norm in Papua to have their own nickname: “film o-ya”. The name derives from the script, which in many films does not go much beyond the repetitive groaning of “Oh yah!, Oh yaaaaaah! Oh yaaaaaaaaah!

A more serious aside: data newly released by the Indonesian Ministry of Health show that one in four of the Papuan women who are selling sex to their men-folk on the streets of the Papuan highland town of Wamena are infected with HIV, while well over half have another STI. Perhaps because condoms don’t fit snugly over the horsehair, three in four of these infected highland women are not using protection with their partners. You don’t need an epidemiologist to tell you what happens next…

Note: This post appeared over at Elizabeth Pisani’s new blog, “Portrait Indonesia”. “Wisdom of Whores” is still on hiatus as she travels Indonesia in preparation for her new book, but we thought that WOW readers might appreciate this particular post. If you’ve not done so already, please do go over to Portrait Indonesia and have a look around. You can get the RSS / Atom feed here.

AIDS prevention poster in Southeastern Maluku, 2011

I have a collection of daft AIDS posters going back years, but I’m glad to say they are getting harder to find. This one, in Saumlaki, the main town in the remote Tanimbar islands, was thus a great find. The headline reads: AIDS: there’s not yet any cure! On the right is this helpful information:

AIDS!!!
You can’t avoid it by:

• Choosing your sex partners on the basis of their appearance
• Drinking/injecting antibiotics, alcohol, or herbal medicine before and after having sex
• Washing your sex organs after having sex

Some, including the South African president Thabo Mbeki and uber-philanthropist Bill Gates would take issue with the last point. I, of course, would take partial issue with the second — you can avoid AIDS by taking medicine, you just can’t avoid HIV that way. But the most egregious part of this ad is the illustration.The population of Tanimbar is largely Melanesian. Overwhelmingly the highest HIV risk for them is the sex they might have on their frequent money-spinning travels to neighbouring Papua. Indonesian Papau, rich in minerals, forests and much else, is swimming in cash. It is also swimming in HIV; it’s epidemic looks more like East Africa 15 years ago than it does like any other part of Indonesia today. And it is populated not by pointy-nosed tourists with straight blonde hair but with flat-nosed Papuans with crinkly black hair.

Most AIDS posters are pretty useless, in my opinion. But this poster associates HIV with Western tourists slow-dancing under the palm trees — an “other” that most people here will never come across, while saying nothing about commercial sex in high risk areas (Papua, but also with the local transgender (or waria) population). Those are very real risks that many certainly do face, at least if Astuti, one of the latter, is to be believed. She excused herself early from a grilled fish dinner because her phone rang. Not her Blackberry, that’s for friends and family, but her “HP selinkungan” (cheating phone). In Tanimbar from neighbouring Kei for around a year, she hasn’t had a day without clients. And though she has helped distribute condoms and promote testing in other cities around Indonesia (in some of which one transgender sex worker in three is infected with HIV), she’s seen no sign of an HIV prevention programme in Tanimbar. By maintaining the fiction that something is being done about HIV prevention in Tanimbar, this poster is a lot worse than useless. It is actively dangerous.

Much has been going on in the world of HIV, sex and drugs in the last month or so; the US marines recruiting at gay community centers, more mysteriously disappointing study outcomes for PrEP, encouraging news about the effect of microbicide gels against herpes, a new super-easy condom with a brand name that will put off anyone who cares about staying power.

I’ve ignored it all. That’s in part because I’ve discovered a site that really says everything that needs to be said about HIV prevention. Particularly insightful, in this post entitled “usefulness connected realizing hiv indicators”, is this gem:

“For that faculty your body gets very suasible to numerous germ infections and so the indicators are sure not e’er the HIV symptoms. The true unique method to aver that a soul is with HIV is the HIV checking.”

I don’t think I can add to that. Which is my polite way of saying that I’m taking a sabbatical from HIV and epidemiology. I plan to spend the next year or so travelling around Indonesia, eventually writing a book about this wonderful and mad land. Which has it’s own fair share of Bad English, as you can see over at my new blog, Portrait Indonesia.

I’ll be spending a lot of time out of range of wi-fi etc., but will try and post at least weekly. If you’d like to follow my progress, you can sign up here.

For now, on the subject of sex and drugs, it’s over and out. Thanks for taking an interest over the last four years.