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’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]

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.

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…