The Accidental Epidemiologist
At the end of that first lecture, the professor asked us a question. Why was there a 14 year gap between the first case-control study showing a strong association between smoking and lung cancer, and the first U.S. Surgeon General’s report on the dangers of smoking?
Stony silence from the highly educated doctors and technicians in the room, men and women who were adding a public health qualification to an existing wealth of medical experience. Maybe this was because it was the first lecture of the year and people were shy. I was not a doctor. I did not have an existing wealth of medical experience. I had not had any scientific education in 25 years. But I was not shy. A journalist’s work depends on a willingness to ask questions of people who are better informed and more powerful than you. It depends on regarding nothing as sacred and everything as open to question. I was by far the least qualified of the 300 or so people in that echoing lecture theatre, but I was full of been-there-done-that bravado. I stuck up my hand.
“You’re asking the wrong question,” I said.
Even I was aware that the air in the lecture theatre had suddenly turned heavy. Heavy enough to crush the bravado. I blundered on, more doubtful now.
“Surely, the key question is: How much money did British American Tobacco and Philip Morris give to US Senate campaigns in that 14 year interval?”
Immediately, there was a shower of laughter and the air cleared. A forest of hands shot up, everyone competing to explain in technical terms that I only partly understood: case-control studies are subject to recall bias, case-control is not the most appropriate method for looking at causes of death, what is really needed to confirm the findings is a cohort study that follows both smokers and non-smokers over time, and and and….
All of these answers were correct, of course. But did that mean the Big Tobacco answer was wrong?
Science does not exist in a vacuum. It exists in a world of money and votes, a world of media enquiry and lobbyists, of pharmaceutical manufacturing and environmental activism and religions and political ideologies and all the other complexities of human life.
Landscapes of Desire
One of the first people we spoke to was Fuad, a 21 year-old lad who occasionally worked as a truck driver’s assistant and who bought sex from waria. Fuad’s girlfriend lived in Bandung, a university town in the cool hills west of Jakarta. Because his truck work was intermittent, he occasionally supplemented his income by giving blow-jobs or selling anal sex to men who cruised in one of Jakarta’s few parks, outside the Finance Ministry beneath the bulging thighs of the monumental, bare-chested Papuan who was symbolically breaking free of the shackles of Dutch colonisation. Sex with men was just a cash thing; Fuad was straight. To remind himself of that, he might occasionally want someone to give him a blow job. But that’s not something you can ask of a “nice girl”; Fuad shared a common perception that oral sex is insulting to women, including to female sex workers. So he went to a transgender sex worker or waria, also known less politely as banci (pronounced banchee).
“If I go to a banci, well, it’s that I’m thinking of my girlfriend.” Fuad told our research team. “I’m 100% into women. Don’t think that because I go to a banci I’m a fag. I’m not into that at all.”
Fuad’s girlfriend was doubtless a nice girl. She also worked the streets of Bandung at night. So here we have a self-proclaimed heterosexual guy who has unpaid sex with a woman who sells sex to other men, while himself also selling sex to other men and buying it from transgendered sex workers. He pushed a lot of the “high risk” buttons for HIV infection, yet he wasn’t a female sex worker, a client, a drug injector, a gay guy or a student. He didn’t fit in to a single one of our questionnaire boxes.
The truth is, real people don’t have sex in boxes.
Emerge after midnight from Jakarta’s stylish Four Seasons Hotel.….and step into the miasma rising off the nearby reservoir. You’ll be assaulted first by the smell, sour, fetid, heavy with the slough of the millions who scratch out lives alongside the city’s waterways. Then come the rats, scuttling purposefully over the moonlit skeletons of daytime food stalls. Finally, as you reach the waste land where miasma meets highway, you’ll come across Lydia or Regina, Olive or Baby – perhaps all of them. Most waria [transgender sex workers] go for the classic “Russian hooker” look – the black PVC skirts stretched tight over the fishnet stockings, plunging into the red patent leather boots. They’ll thrust their butt out to the left, dangle their cute imitation Chanel purse to the right – the pose will show off the new breast implants as well as helping them balance on those vertiginous heels.
There’s always a lot of flicking of hairdos and endless public display of lip gloss. There are two types of interaction with the slowly cruising cars that hold the lusty, the unfulfilled or the just plain curious. One is a nonchalant disregard; the “girls” chat with one another and feign mild annoyance at being interrupted by guys wanting to negotiate for their services. “I don’t need you that badly, so you’d better make it worth my while” is the sales message projected by this crew. The other approach is more brazen – glittering gowns are thrown open as a car crawls up; the full panoply of wares put on display. This sales pitch is favoured by those who have invested their savings in sex change operations. “Soooooo over the top,” sulked Nancy, leader of Jakarta’s well-organised waria community. She herself would never trade orgasms for an operation, she says, but I can’t help feeling she’s a tiny bit jealous.
Lenny, another doyenne of the city’s transgender hookers who was putting on her make-up while Nancy pontificated, laughed. Lenny is not thrilled that the Department of Social Affairs has tossed her, along with all waria, into a box marked “mentally disabled”. But she had to agree with “over the top”. Lenny had organised a group that was lobbying for equal rights for waria. She interrupted her face-paint rituals to tell of a recent meeting with a parliamentary sub-committee. “We’re in the national parliament asking to be taken seriously as a community, and I see that two of the girls are missing. I send someone off to look for them and guess what? They’re screwing the security guards in the bathroom.” She shook her head in disbelief and went back to her mascara.
Nancy perked up again at the tale. She had reported the miscreants to their mami, the long-established cell mothers who oversee the younger waria. “They beat the shit out of them,” she said, with visible satisfaction. “No respect, that’s the trouble with youngsters these days, no respect.”
The honesty box
Jabbing needles into inebriated gay boys in smoky nightclubs is always hard work; all in all it had been a long night. By about three in the morning we had 41 blood samples on ice. The doof-doof music continued to throb around us, but most of the people still on the dance floor were by now too high to answer our questions. I decided to call it a night. The team packed up, and I strapped damask tablecloths, a cooler full of blood and a bag of used syringes to the back of my motorbike and set off for the laboratory.
Ahead loomed a police road block – a drug raid. Inconvenient. The cops want evidence of drug-related activity, and I am carrying 41 used syringes. In a city where heroin is sometimes sold together with the means to take it, who but a drug dealer would have such a thing?
To make matters worse, these were not just any cops. The most reliable guide to a policeman’s rank in Indonesia is not his epaulettes but his girth. The higher the rank, the better they are at extracting bribes. The better they are at extracting bribes, the larger the girth. Here in front of me, I had Tweedledum and Tweedledee. They were so fixated on my cache of bloody syringes that they barely registered any surprise that a small white women should be driving a motorbike through the entrails of Jakarta’s “entertainment district” in the small hours of the morning.
Like everything in Indonesia, this can be resolved with a dash of cash, which I keep clipped to the back of my driving licence for just such occasions. I reached for my wallet. But damnation, not content to deprive me of sleep, fill my lungs with smoke and ravage my ears with techno, Jakarta’s gay scene harboured a thief who had swiped my wallet. Tweedledum and Tweedledee didn’t mind: They’d impound my cooler as “evidence”, they said, and I could pay my “fine” when I picked it up the next day.
By which time, of course, the blood would be ruined. That would be about an eighth of the entire study down the drain – and I didn’t think the team could face another session at the Moonlight. I was limp with exhaustion and could feel my resolve sapping. Perhaps I should just give them the cooler and drive off. But the boys in Moonlight are special, they are cops and robbers, students and street vendors. They are not like the well-heeled guys who go to Prego and most of the other gay bars. If I ditched these samples, the study results could be badly skewed.
One last try. “Of course, officer, I do understand. You’re just doing your job.” I handed over the cooler, smiling sweetly. “Oh, here, you’d better take some of these, too.” I fished out a handful of latex gloves. “You just can’t be too careful with HIV infected blood.” The expression on those sleek-headed cops’ faces imploded from self-satisfaction to horror. They thrust the poisonous blood back at me. Twenty minutes later the samples were at the lab, and I could go back to worrying about whether they would be tested using reliable kits and clean pipette tips.
Ants in the sugar bowl
You might think that a bit of good, free-market competition is just what these bloated NGOs need to shake them up and increase efficiency. And you’d be right. Except that the AIDS industry isn’t a free market. As we’ve seen, you rarely have to say what your “bottom line” is — how many infections you’ll prevent. And you almost never have to show you’ve prevented any infections. You can be judged a success for just doing what you said you were going to do, like build a clinic, or train some nurses or give leaflets to 400 out of the nation’s 160,000 drug injectors. It’s a bit like declaring that Ford is doing really well in the car market because they’ve got factories and floor managers and an advertising campaign, instead of looking at sales figures. Or even checking that they make cars that run.
In the AIDS industry, most people do whatever projects pay them to do. “In fact, we don’t have time to do any real work,” protested a Chinese colleague, whom I’ll call Wang. He was from the local health department in Dali, a Wild West town on the opium-sodden border between Yunnan and Burma. Huge casinos just inside Burma acted as a magnet for gamblers from all over China, and gamblers acted as a magnet for prostitutes. Wang had been pulled out of Dali to be trained in how to estimate the number of prostitutes locally, and he was quite cross about it. He’d already counted prostitutes in Dali three times in the previous year, he said. Once for the China-UK prevention programme, once for a US-funded programme and once for the Chinese government. Now he was being asked to do it again with Global Fund money. “Count, count, count. And no money for prevention.” Wang was getting louder as he got more worked up. I could see why he was upset. “Why don’t you just give the donors all the same count and have done with it?” I asked. Wang looked shocked. “But they’ve all given me money to count!” he bellowed. “If I didn’t count for each of them, that would be corruption!” …
Too many AIDS programmes spoil the broth for the people like Wang who are just trying to get on with delivering services to people who need them. And the problem is getting worse all the time. The US government, for example, works mostly through Beltway Bandits and church groups. It won’t give more than eight percent of its money in any one country to a single organisation. That’s a minimum of 13 separate first-line contractors getting US money in any given country. That’s 13 country directors, with nice rented villas and kids in expensive international schools. It’s 13 offices, 13 finance directors, 13 janitors, 13 photocopiers. It’s 13 separate organisations trying to hire the best and the brightest away from the national institutions they work in, and 13 organisations trying to organise capacity building workshops to replace the skills they’ve stolen. Each organisation is clamouring for the time and attention of whoever’s left in the national AIDS programme, and each is trying to pass money on down the line to the few local institutions and NGOs who can actually do what’s needed on the ground. The good NGOs might get money from three or four of the Bandits, and they’ll have to write separate monthly, quarterly and annual reports for each of them. In the best of all possible worlds, the naked inter-agency competition is tempered by a sense of a common goal. As one weary-sounding colleague describes the result, he reminds me forcefully of Wang: “We can’t get any work done. We’re all too busy co-ordinating with one another.”