ABOUT THE SPEAKER
Elizabeth Pisani - Author
In Elizabeth Pisani's latest book, she explores the "improbable nation" of Indonesia.

Why you should listen
In fast-emerging Asia there is one nation that, despite being the world's fourth most-populous (and the third most-populous democracy) and the largest Muslim country (with 210 million people who identify themselves as such), is also, as Elizabeth Pisani writes, "probably the most invisible country in the world". Indonesia. An archipelago of over 17,000 islands that span a distance like that from New York to Alaska, with over 700 languages and a dynamic economy -- but which, puzzingly, doesn't really feature in the global imagination.

Pisani spent two years travelling 23,000 kilometers by boat, bus and motorbike through Indonesia, a place that has fascinated and maddened her since she first lived there over two decades ago. Her portrait of the country, the recent Indonesia Etc.: Exploring the Improbable Nation, reveals the archipelago's complexity and contradictions, a fascinating diversity that "is not just geographic and cultural: different groups are essentially living at different points in human history, all at the same time."

An alumna of various government health agencies, Pisani became an assumption-busting independent researcher and analyst, polling transgendered sex workers, drug addicts and others to illuminate the surprising (and often ignored) demographics that belie traditional studies.

Pisani is fearlessly outspoken on the global failure to understand and manage the realities of AIDS, decrying the tangled roles that money, votes, and media play in the public health landscape. She shows how politics and "morality" have hogtied funding, and advocates for putting dollars where they can actually make a difference. As the Globe and Mail wrote: “Pisani is lucid, colourful, insightful and impatient.”

More profile about the speaker
Elizabeth Pisani | Speaker | TED.com
TED2010

Elizabeth Pisani: Sex, drugs and HIV -- let's get rational

Filmed:
1,494,475 views

Armed with bracing logic, wit and her "public-health nerd" glasses, Elizabeth Pisani reveals the myriad of inconsistencies in today's political systems that prevent our dollars from effectively fighting the spread of HIV. Her research with at-risk populations -- from junkies in prison to sex workers on the street in Cambodia -- demonstrates the sometimes counter-intuitive measures that could stall the spread of this devastating disease.
- Author
In Elizabeth Pisani's latest book, she explores the "improbable nation" of Indonesia. Full bio

Double-click the English transcript below to play the video.

00:16
"People do stupid things.
0
1000
2000
00:18
That's what spreads HIV."
1
3000
2000
00:20
This was a headline in a U.K. newspaper,
2
5000
2000
00:22
The Guardian, not that long ago.
3
7000
2000
00:24
I'm curious, show of hands, who agrees with it?
4
9000
3000
00:29
Well, one or two brave souls.
5
14000
2000
00:31
This is actually a direct quote from an epidemiologist
6
16000
3000
00:34
who's been in field of HIV for 15 years,
7
19000
2000
00:36
worked on four continents,
8
21000
2000
00:38
and you're looking at her.
9
23000
2000
00:40
And I am now going to argue
10
25000
2000
00:42
that this is only half true.
11
27000
2000
00:44
People do get HIV because they do stupid things,
12
29000
3000
00:47
but most of them are doing stupid things
13
32000
2000
00:49
for perfectly rational reasons.
14
34000
3000
00:52
Now, "rational" is the dominant paradigm
15
37000
3000
00:55
in public health,
16
40000
2000
00:57
and if you put your public health nerd glasses on,
17
42000
3000
01:00
you'll see that if we give people the information that they need
18
45000
3000
01:03
about what's good for them and what's bad for them,
19
48000
2000
01:05
if you give them the services
20
50000
2000
01:07
that they can use to act on that information,
21
52000
2000
01:09
and a little bit of motivation,
22
54000
2000
01:11
people will make rational decisions
23
56000
2000
01:13
and live long and healthy lives.
24
58000
2000
01:15
Wonderful.
25
60000
2000
01:17
That's slightly problematic for me because I work in HIV,
26
62000
3000
01:20
and although I'm sure you all know
27
65000
2000
01:22
that HIV is about poverty and gender inequality,
28
67000
3000
01:25
and if you were at TED '07
29
70000
2000
01:27
it's about coffee prices ...
30
72000
2000
01:29
Actually, HIV's about sex and drugs,
31
74000
3000
01:32
and if there are two things that make
32
77000
2000
01:34
human beings a little bit irrational,
33
79000
2000
01:36
they are erections and addiction.
34
81000
3000
01:39
(Laughter)
35
84000
2000
01:41
So, let's start with what's rational for an addict.
36
86000
3000
01:44
Now, I remember speaking to an Indonesian friend of mine, Frankie.
37
89000
3000
01:47
We were having lunch and he was telling me
38
92000
2000
01:49
about when he was in jail in Bali for a drug injection.
39
94000
3000
01:52
It was someone's birthday, and they had very kindly
40
97000
2000
01:54
smuggled some heroin into jail,
41
99000
2000
01:56
and he was very generously sharing it out
42
101000
3000
01:59
with all of his colleagues.
43
104000
2000
02:01
And so everyone lined up,
44
106000
2000
02:03
all the smackheads in a row,
45
108000
2000
02:05
and the guy whose birthday it was
46
110000
2000
02:07
filled up the fit,
47
112000
3000
02:10
and he went down and started injecting people.
48
115000
2000
02:12
So he injects the first guy,
49
117000
2000
02:14
and then he's wiping the needle on his shirt,
50
119000
3000
02:17
and he injects the next guy.
51
122000
2000
02:19
And Frankie says, "I'm number 22 in line,
52
124000
4000
02:23
and I can see the needle coming down towards me,
53
128000
3000
02:26
and there is blood all over the place.
54
131000
2000
02:28
It's getting blunter and blunter.
55
133000
2000
02:30
And a small part of my brain is thinking,
56
135000
3000
02:33
'That is so gross
57
138000
2000
02:35
and really dangerous,'
58
140000
2000
02:37
but most of my brain is thinking,
59
142000
2000
02:39
'Please let there be some smack left
60
144000
2000
02:41
by the time it gets to me.
61
146000
2000
02:43
Please let there be some left.'"
62
148000
2000
02:45
And then, telling me this story,
63
150000
2000
02:47
Frankie said,
64
152000
2000
02:49
"You know ... God,
65
154000
2000
02:51
drugs really make you stupid."
66
156000
3000
02:55
And, you know, you can't fault him for accuracy.
67
160000
3000
02:58
But, actually, Frankie, at that time,
68
163000
3000
03:01
was a heroin addict and he was in jail.
69
166000
2000
03:03
So his choice was either
70
168000
2000
03:05
to accept that dirty needle or not to get high.
71
170000
3000
03:08
And if there's one place you really want to get high,
72
173000
2000
03:10
it's when you're in jail.
73
175000
2000
03:12
But I'm a scientist
74
177000
2000
03:14
and I don't like to make data out of anecdotes,
75
179000
2000
03:16
so let's look at some data.
76
181000
2000
03:18
We talked to 600 drug addicts
77
183000
3000
03:21
in three cities in Indonesia,
78
186000
2000
03:23
and we said, "Well, do you know how you get HIV?"
79
188000
2000
03:25
"Oh yeah, by sharing needles."
80
190000
2000
03:27
I mean, nearly 100 percent. Yeah, by sharing needles.
81
192000
3000
03:30
And, "Do you know where you can get a clean needle
82
195000
2000
03:32
at a price you can afford to avoid that?"
83
197000
2000
03:34
"Oh yeah." Hundred percent.
84
199000
2000
03:36
"We're smackheads; we know where to get clean needles."
85
201000
2000
03:38
"So are you carrying a needle?"
86
203000
2000
03:40
We're actually interviewing people on the street,
87
205000
2000
03:42
in the places where they're hanging out and taking drugs.
88
207000
2000
03:44
"Are you carrying clean needles?"
89
209000
2000
03:46
One in four, maximum.
90
211000
3000
03:49
So no surprises then that
91
214000
2000
03:51
the proportion that actually used clean needles
92
216000
2000
03:53
every time they injected in the last week
93
218000
2000
03:55
is just about one in 10,
94
220000
3000
03:58
and the other nine in 10 are sharing.
95
223000
3000
04:01
So you've got this massive mismatch;
96
226000
2000
04:03
everyone knows that
97
228000
2000
04:05
if they share they're going to get HIV,
98
230000
2000
04:07
but they're all sharing anyway.
99
232000
2000
04:09
So what's that about? Is it like you get a better high if you share or something?
100
234000
3000
04:12
We asked that to a junkie and they're like, "Are you nuts?"
101
237000
3000
04:15
You don't want to share a needle anymore than you want
102
240000
2000
04:17
to share a toothbrush even with someone you're sleeping with.
103
242000
3000
04:20
There's just kind of an ick factor there.
104
245000
2000
04:22
"No, no. We share needles because we don't want to go to jail."
105
247000
3000
04:26
So, in Indonesia at this time,
106
251000
3000
04:29
if you were carrying a needle and the cops rounded you up,
107
254000
3000
04:32
they could put you into jail.
108
257000
2000
04:34
And that changes the equation slightly, doesn't it?
109
259000
2000
04:36
Because your choice now is either
110
261000
3000
04:39
I use my own needle now,
111
264000
4000
04:43
or I could share a needle now
112
268000
2000
04:45
and get a disease that's going to
113
270000
2000
04:47
possibly kill me 10 years from now,
114
272000
2000
04:49
or I could use my own needle now
115
274000
3000
04:52
and go to jail tomorrow.
116
277000
3000
04:55
And while junkies think that
117
280000
2000
04:57
it's a really bad idea to expose themselves to HIV,
118
282000
3000
05:00
they think it's a much worse idea
119
285000
2000
05:02
to spend the next year in jail
120
287000
2000
05:04
where they'll probably end up in Frankie's situation
121
289000
2000
05:06
and expose themselves to HIV anyway.
122
291000
3000
05:09
So, suddenly it becomes perfectly rational
123
294000
2000
05:11
to share needles.
124
296000
2000
05:13
Now, let's look at it from a policy maker's point of view.
125
298000
2000
05:15
This is a really easy problem.
126
300000
2000
05:17
For once, your incentives are aligned.
127
302000
3000
05:20
We've got what's rational for public health.
128
305000
3000
05:23
You want people to use clean needles --
129
308000
2000
05:25
and junkies want to use clean needles.
130
310000
2000
05:27
So we could make this problem go away
131
312000
2000
05:29
simply by making clean needles universally available
132
314000
3000
05:32
and taking away the fear of arrest.
133
317000
2000
05:34
Now, the first person to figure that out
134
319000
2000
05:36
and do something about it on a national scale
135
321000
2000
05:38
was that well-known, bleeding heart liberal
136
323000
3000
05:41
Margaret Thatcher.
137
326000
2000
05:43
And she put in the world's first
138
328000
2000
05:45
national needle exchange program,
139
330000
2000
05:47
and other countries followed suit: Australia, The Netherlands and few others.
140
332000
3000
05:50
And in all of those countries, you can see,
141
335000
2000
05:52
not more than four percent of injectors
142
337000
2000
05:54
ever became infected with HIV.
143
339000
3000
05:57
Now, places that didn't do this -- New York City for example,
144
342000
3000
06:00
Moscow, Jakarta --
145
345000
2000
06:02
we're talking, at its peak,
146
347000
2000
06:04
one in two injectors
147
349000
3000
06:07
infected with this fatal disease.
148
352000
3000
06:10
Now, Margaret Thatcher didn't do this
149
355000
2000
06:12
because she has any great love for junkies.
150
357000
3000
06:15
She did it because she ran a country
151
360000
3000
06:18
that had a national health service.
152
363000
2000
06:20
So, if she didn't invest in effective prevention,
153
365000
3000
06:23
she was going to have pick up the costs
154
368000
2000
06:25
of treatment later on,
155
370000
2000
06:27
and obviously those are much higher.
156
372000
2000
06:29
So she was making a politically rational decision.
157
374000
3000
06:32
Now, if I take out my
158
377000
2000
06:34
public health nerd glasses here
159
379000
2000
06:36
and look at these data,
160
381000
3000
06:39
it seems like a no-brainer, doesn't it?
161
384000
3000
06:42
But in this country,
162
387000
2000
06:44
where the government apparently does not feel compelled
163
389000
3000
06:47
to provide health care for citizens, (Laughter)
164
392000
2000
06:49
we've taken a very different approach.
165
394000
3000
06:52
So what we've been doing in the United States
166
397000
2000
06:54
is reviewing the data -- endlessly reviewing the data.
167
399000
3000
06:57
So, these are reviews of hundreds of studies
168
402000
3000
07:00
by all the big muckety-mucks
169
405000
2000
07:02
of the scientific pantheon in the United States,
170
407000
3000
07:05
and these are the studies that show
171
410000
2000
07:07
needle programs are effective -- quite a lot of them.
172
412000
2000
07:09
Now, the ones that show that needle programs aren't effective --
173
414000
3000
07:12
you think that's one of these annoying dynamic slides
174
417000
3000
07:15
and I'm going to press my dongle and the rest of it's going to come up,
175
420000
2000
07:17
but no -- that's the whole slide.
176
422000
3000
07:20
(Laughter)
177
425000
2000
07:22
There is nothing on the other side.
178
427000
3000
07:27
So, completely irrational,
179
432000
2000
07:29
you would think.
180
434000
2000
07:31
Except that, wait a minute, politicians are rational, too,
181
436000
3000
07:34
and they're responding to what they think the voters want.
182
439000
3000
07:37
So what we see is that voters respond
183
442000
2000
07:39
very well to things like this
184
444000
2000
07:41
and not quite so well to things like this.
185
446000
3000
07:44
(Laughter)
186
449000
7000
07:51
So it becomes quite rational
187
456000
3000
07:54
to deny services to injectors.
188
459000
3000
07:57
Now let's talk about sex.
189
462000
2000
07:59
Are we any more rational about sex?
190
464000
3000
08:02
Well, I'm not even going to address
191
467000
2000
08:04
the clearly irrational positions
192
469000
2000
08:06
of people like the Catholic Church,
193
471000
2000
08:08
who think somehow that if you give out condoms,
194
473000
3000
08:11
everyone's going to run out and have sex.
195
476000
4000
08:15
I don't know if Pope Benedict
196
480000
2000
08:17
watches TEDTalks online,
197
482000
2000
08:19
but if you do, I've got news for you Benedict --
198
484000
3000
08:22
I carry condoms all the time
199
487000
3000
08:25
and I never get laid.
200
490000
2000
08:27
(Laughter) (Applause)
201
492000
2000
08:29
It's not that easy!
202
494000
2000
08:31
Here, maybe you'll have better luck.
203
496000
2000
08:33
(Applause)
204
498000
6000
08:39
Okay, seriously,
205
504000
2000
08:41
HIV is actually not that easy
206
506000
3000
08:44
to transmit sexually.
207
509000
2000
08:46
So, it depends on how much virus there is
208
511000
2000
08:48
in your blood and in your body fluids.
209
513000
2000
08:50
And what we've got is a very, very high level of virus
210
515000
3000
08:53
right at the beginning when you're first infected,
211
518000
2000
08:55
then you start making antibodies,
212
520000
2000
08:57
and then it bumps along at quite low levels
213
522000
2000
08:59
for a long time -- 10 or 12 years --
214
524000
2000
09:01
you have spikes if you get another sexually transmitted infection.
215
526000
3000
09:04
But basically, nothing much is going on
216
529000
2000
09:06
until you start to get symptomatic AIDS,
217
531000
2000
09:08
and by that stage,
218
533000
2000
09:10
you're not looking great, you're not feeling great,
219
535000
2000
09:12
you're not having that much sex.
220
537000
2000
09:14
So the sexual transmission of HIV
221
539000
2000
09:16
is essentially determined by how many partners you have
222
541000
3000
09:19
in these very short spaces of time
223
544000
3000
09:22
when you have peak viremia.
224
547000
2000
09:24
Now, this makes people crazy
225
549000
3000
09:27
because it means that you have to talk about
226
552000
3000
09:30
some groups having more sexual partners
227
555000
2000
09:32
in shorter spaces of time than other groups,
228
557000
2000
09:34
and that's considered stigmatizing.
229
559000
2000
09:36
I've always been a bit curious about that
230
561000
2000
09:38
because I think stigma is a bad thing,
231
563000
2000
09:40
whereas lots of sex is quite a good thing,
232
565000
2000
09:42
but we'll leave that be.
233
567000
3000
09:45
The truth is that 20 years
234
570000
2000
09:47
of very good research
235
572000
2000
09:49
have shown us that
236
574000
2000
09:51
there are groups that are more likely to turnover
237
576000
3000
09:54
large numbers of partners in a short space of time.
238
579000
2000
09:56
And those groups are, globally,
239
581000
2000
09:58
people who sell sex and their more regular partners.
240
583000
3000
10:01
They are gay men on the party scene
241
586000
2000
10:03
who have, on average, three times more partners
242
588000
2000
10:05
than straight people on the party scene.
243
590000
2000
10:07
And they are heterosexuals
244
592000
2000
10:09
who come from countries that have
245
594000
2000
10:11
traditions of polygamy
246
596000
2000
10:13
and relatively high levels of female autonomy,
247
598000
3000
10:16
and almost all of those countries are in east or southern Africa.
248
601000
3000
10:19
And that is reflected in the epidemic that we have today.
249
604000
3000
10:22
You can see these horrifying figures from Africa.
250
607000
3000
10:25
These are all countries in southern Africa
251
610000
2000
10:27
where between one in seven,
252
612000
2000
10:29
and one in three
253
614000
2000
10:31
of all adults,
254
616000
2000
10:33
are infected with HIV.
255
618000
2000
10:35
Now, in the rest of the world,
256
620000
2000
10:37
we've got basically nothing going on in the general population --
257
622000
3000
10:40
very, very low levels --
258
625000
2000
10:42
but we have extraordinarily high levels of HIV
259
627000
3000
10:45
in these other populations who are at highest risk:
260
630000
3000
10:48
drug injectors, sex workers
261
633000
2000
10:50
and gay men.
262
635000
2000
10:52
And you'll note, that's the local data from Los Angeles:
263
637000
2000
10:54
25 percent prevalence among gay men.
264
639000
3000
10:58
Of course, you can't get HIV just by having unprotected sex.
265
643000
3000
11:01
You can only HIV by having unprotected sex
266
646000
3000
11:04
with a positive person.
267
649000
3000
11:07
In most of the world,
268
652000
2000
11:09
these few prevention failures
269
654000
2000
11:11
notwithstanding,
270
656000
2000
11:13
we are actually doing quite well these days
271
658000
2000
11:15
in commercial sex:
272
660000
2000
11:17
condom use rates are between 80 and 100 percent
273
662000
2000
11:19
in commercial sex in most countries.
274
664000
3000
11:22
And, again, it's because of an alignment of the incentives.
275
667000
3000
11:25
What's rational for public health
276
670000
2000
11:27
is also rational for individual sex workers
277
672000
2000
11:29
because it's really bad for business to have another STI.
278
674000
3000
11:32
No one wants it.
279
677000
2000
11:34
And, actually, clients don't want to go home with a drip either.
280
679000
2000
11:36
So essentially, you're able to achieve
281
681000
3000
11:39
quite high rates of condom use in commercial sex.
282
684000
3000
11:42
But in "intimate" relations
283
687000
2000
11:44
it's much more difficult because,
284
689000
2000
11:46
with your wife or your boyfriend
285
691000
2000
11:48
or someone that you hope might turn into one of those things,
286
693000
3000
11:51
we have this illusion of romance
287
696000
3000
11:54
and trust and intimacy,
288
699000
2000
11:56
and nothing is quite so unromantic
289
701000
3000
11:59
as the, "My condom or yours, darling?" question.
290
704000
3000
12:02
So in the face of that,
291
707000
3000
12:05
you really need quite a strong incentive
292
710000
3000
12:08
to use condoms.
293
713000
3000
12:11
This, for example, this gentleman is called Joseph.
294
716000
3000
12:14
He's from Haiti and he has AIDS.
295
719000
2000
12:16
And he's probably not having a lot of sex right now,
296
721000
3000
12:19
but he is a reminder in the population,
297
724000
2000
12:21
of why you might want to be
298
726000
2000
12:23
using condoms.
299
728000
2000
12:25
This is also in Haiti and is a reminder
300
730000
2000
12:27
of why you might want to be having sex, perhaps.
301
732000
3000
12:31
Now, funnily enough, this is also Joseph
302
736000
3000
12:34
after six months on antiretroviral treatment.
303
739000
3000
12:38
Not for nothing do we call it the Lazarus Effect.
304
743000
3000
12:43
But it is changing the equation
305
748000
3000
12:46
of what's rational
306
751000
2000
12:48
in sexual decision-making.
307
753000
3000
12:51
So, what we've got --
308
756000
2000
12:53
some people say, "Oh, it doesn't matter very much
309
758000
2000
12:55
because, actually, treatment is effective prevention
310
760000
3000
12:58
because it lowers your viral load and therefore
311
763000
2000
13:00
makes it more difficult to transmit HIV."
312
765000
2000
13:02
So, if you look at the viremia thing again,
313
767000
3000
13:05
if you do start treatment when you're sick,
314
770000
2000
13:07
well, what happens? Your viral load comes down.
315
772000
3000
13:10
But compared to what? What happens if you're not on treatment?
316
775000
3000
13:14
Well, you die,
317
779000
2000
13:16
so your viral load goes to zero.
318
781000
2000
13:18
And all of this green stuff here, including the spikes --
319
783000
3000
13:21
which are because you couldn't get to the pharmacy,
320
786000
4000
13:25
or you ran out of drugs, or you went on a three day party binge
321
790000
3000
13:28
and forgot to take your drugs,
322
793000
2000
13:30
or because you've started to get resistance, or whatever --
323
795000
3000
13:33
all of that is virus
324
798000
2000
13:35
that wouldn't be out there, except for treatment.
325
800000
3000
13:38
Now, am I saying, "Oh, well, great prevention strategy.
326
803000
3000
13:41
Let's just stop treating people."
327
806000
2000
13:43
Of course not, of course not.
328
808000
2000
13:45
We need to expand antiretroviral treatment as much as we can.
329
810000
3000
13:48
But what I am doing is calling into question
330
813000
2000
13:50
those people who say that more treatment
331
815000
2000
13:52
is all the prevention we need.
332
817000
2000
13:54
That's simply not necessarily true,
333
819000
3000
13:57
and I think we can learn a lot from the experience of gay men
334
822000
2000
13:59
in rich countries where treatment has been widely available
335
824000
3000
14:02
for going on 15 years now.
336
827000
2000
14:04
And what we've seen is
337
829000
2000
14:06
that, actually, condom use rates,
338
831000
2000
14:08
which were very, very high --
339
833000
2000
14:10
the gay community responded very rapidly to HIV,
340
835000
3000
14:13
with extremely little help
341
838000
2000
14:15
from public health nerds, I would say --
342
840000
2000
14:17
that condom use rate has come down dramatically since treatment
343
842000
3000
14:20
for two reasons really:
344
845000
2000
14:22
One is the assumption of, "Oh well,
345
847000
2000
14:24
if he's infected, he's probably on meds,
346
849000
2000
14:26
and his viral load's going to be low, so I'm pretty safe."
347
851000
3000
14:29
And the other thing is that people are simply
348
854000
2000
14:31
not as scared of HIV
349
856000
2000
14:33
as they were of AIDS, and rightly so.
350
858000
3000
14:36
AIDS was a disfiguring disease that killed you,
351
861000
3000
14:39
and HIV is an invisible virus
352
864000
2000
14:41
that makes you take a pill every day.
353
866000
2000
14:43
And that's boring,
354
868000
2000
14:45
but is it as boring as
355
870000
3000
14:48
having to use a condom every time you have sex,
356
873000
2000
14:50
no matter how drunk you are,
357
875000
2000
14:52
no matter how many poppers you've taken, whatever?
358
877000
3000
14:55
If we look at the data, we can see that
359
880000
2000
14:57
the answer to that question
360
882000
2000
14:59
is, mmm.
361
884000
2000
15:01
So these are data from Scotland.
362
886000
2000
15:03
You see the peak in drug injectors
363
888000
2000
15:05
before they started the national needle exchange program.
364
890000
2000
15:07
Then it came way down.
365
892000
2000
15:09
And both in heterosexuals -- mostly in commercial sex --
366
894000
2000
15:11
and in drug users,
367
896000
2000
15:13
you've really got nothing much going on after treatment begins,
368
898000
3000
15:16
and that's because of that alignment of incentives
369
901000
2000
15:18
that I talked about earlier.
370
903000
2000
15:20
But in gay men,
371
905000
2000
15:22
you've got quite a dramatic rise
372
907000
2000
15:24
starting three or four years
373
909000
2000
15:26
after treatment became widely available.
374
911000
2000
15:28
This is of new infections.
375
913000
2000
15:30
What does that mean?
376
915000
2000
15:32
It means that the combined effect of being less worried
377
917000
3000
15:35
and having more virus out there in the population --
378
920000
3000
15:38
more people living longer, healthier lives,
379
923000
2000
15:40
more likely to be getting laid
380
925000
2000
15:42
with HIV --
381
927000
2000
15:44
is outweighing the effects of lower viral load,
382
929000
3000
15:47
and that's a very worrisome thing.
383
932000
2000
15:49
What does it mean?
384
934000
2000
15:51
It means we need to be doing more prevention the more treatment we have.
385
936000
3000
15:54
Is that what's happening?
386
939000
2000
15:56
No, and I call it the "compassion conundrum."
387
941000
3000
15:59
We've talked a lot about compassion the last couple of days,
388
944000
3000
16:02
and what's happening really is that people are
389
947000
3000
16:05
unable quite to bring themselves to put in
390
950000
2000
16:07
good sexual and reproductive health services for sex workers,
391
952000
3000
16:10
unable quite to be giving out needles to junkies.
392
955000
3000
16:13
But once they've gone from being
393
958000
3000
16:16
transgressive people whose behaviors we don't want to condone
394
961000
3000
16:19
to being AIDS victims,
395
964000
2000
16:21
we come over all compassionate
396
966000
2000
16:23
and buy them incredibly expensive drugs for the rest of their lives.
397
968000
2000
16:25
It doesn't make any sense
398
970000
2000
16:27
from a public health point of view.
399
972000
2000
16:29
I want to give what's very nearly the last word to Ines.
400
974000
4000
16:33
Ines is a a transgender hooker on the streets of Jakarta;
401
978000
3000
16:36
she's a chick with a dick.
402
981000
2000
16:38
Why does she do that job?
403
983000
2000
16:40
Well, of course, because she's forced into it
404
985000
3000
16:43
because she doesn't have any better option, etc., etc.
405
988000
2000
16:45
And if we could just teach her to sew
406
990000
2000
16:47
and get her a nice job in a factory, all would be well.
407
992000
3000
16:50
This is what factory workers earn in an hour in Indonesia:
408
995000
2000
16:52
on average, 20 cents.
409
997000
2000
16:54
It varies a bit province to province.
410
999000
2000
16:56
I do speak to sex workers, 15,000 of them
411
1001000
3000
16:59
for this particular slide,
412
1004000
2000
17:01
and this is what sex workers
413
1006000
2000
17:03
say they earn in an hour.
414
1008000
2000
17:05
So it's not a great job, but for a lot of people
415
1010000
3000
17:08
it really is quite a rational choice.
416
1013000
2000
17:10
Okay, Ines.
417
1015000
2000
17:15
We've got the tools, the knowledge and the cash,
418
1020000
5000
17:20
and commitment to preventing HIV too.
419
1025000
4000
17:24
Ines: So why is prevalence still rising?
420
1029000
6000
17:30
It's all politics.
421
1035000
3000
17:33
When you get to politics, nothing makes sense.
422
1038000
3000
17:36
Elizabeth Pisani: "When you get to politics, nothing makes sense."
423
1041000
3000
17:39
So, from the point of view of a sex worker,
424
1044000
3000
17:42
politicians are making no sense.
425
1047000
2000
17:44
From the point of view of a public health nerd,
426
1049000
2000
17:46
junkies are doing dumb things.
427
1051000
3000
17:50
The truth is that everyone has a different rationale.
428
1055000
3000
17:53
There are as many different ways of being rational
429
1058000
2000
17:55
as there are human beings on the planet,
430
1060000
2000
17:57
and that's one of the glories of human existence.
431
1062000
2000
17:59
But those ways of being rational
432
1064000
2000
18:01
are not independent of one another,
433
1066000
2000
18:03
so it's rational for
434
1068000
2000
18:05
a drug injector to share needles
435
1070000
2000
18:07
because of a stupid decision that's made by a politician,
436
1072000
3000
18:10
and it's rational for a politician
437
1075000
2000
18:12
to make that stupid decision
438
1077000
3000
18:15
because they're responding to
439
1080000
2000
18:17
what they think the voters want.
440
1082000
2000
18:19
But here's the thing:
441
1084000
2000
18:21
we are the voters.
442
1086000
2000
18:23
We're not all of them, of course, but TED is a community of opinion leaders.
443
1088000
3000
18:26
And everyone who's in this room,
444
1091000
2000
18:28
and everyone who's watching this out there on the web,
445
1093000
3000
18:31
I think, has a duty to demand of their politicians
446
1096000
3000
18:34
that we make policy based on scientific evidence
447
1099000
3000
18:37
and on common sense.
448
1102000
2000
18:39
It's going to be really hard for us
449
1104000
2000
18:41
to individually affect what's rational
450
1106000
3000
18:44
for every Frankie and every Ines out there,
451
1109000
2000
18:46
but you can at least use your vote
452
1111000
3000
18:49
to stop politicians doing stupid things
453
1114000
3000
18:52
that spread HIV.
454
1117000
2000
18:54
Thank you.
455
1119000
2000
18:56
(Applause)
456
1121000
9000

▲Back to top

ABOUT THE SPEAKER
Elizabeth Pisani - Author
In Elizabeth Pisani's latest book, she explores the "improbable nation" of Indonesia.

Why you should listen
In fast-emerging Asia there is one nation that, despite being the world's fourth most-populous (and the third most-populous democracy) and the largest Muslim country (with 210 million people who identify themselves as such), is also, as Elizabeth Pisani writes, "probably the most invisible country in the world". Indonesia. An archipelago of over 17,000 islands that span a distance like that from New York to Alaska, with over 700 languages and a dynamic economy -- but which, puzzingly, doesn't really feature in the global imagination.

Pisani spent two years travelling 23,000 kilometers by boat, bus and motorbike through Indonesia, a place that has fascinated and maddened her since she first lived there over two decades ago. Her portrait of the country, the recent Indonesia Etc.: Exploring the Improbable Nation, reveals the archipelago's complexity and contradictions, a fascinating diversity that "is not just geographic and cultural: different groups are essentially living at different points in human history, all at the same time."

An alumna of various government health agencies, Pisani became an assumption-busting independent researcher and analyst, polling transgendered sex workers, drug addicts and others to illuminate the surprising (and often ignored) demographics that belie traditional studies.

Pisani is fearlessly outspoken on the global failure to understand and manage the realities of AIDS, decrying the tangled roles that money, votes, and media play in the public health landscape. She shows how politics and "morality" have hogtied funding, and advocates for putting dollars where they can actually make a difference. As the Globe and Mail wrote: “Pisani is lucid, colourful, insightful and impatient.”

More profile about the speaker
Elizabeth Pisani | Speaker | TED.com