Greater Minds: Elizabeth Pisani on rational stupidity and AIDS

  • Photo1

    Elizabeth Pisani in 2015 (TED Conference [CC / Flickr])

    Elizabeth Pisani is an HIV epidemiologist and author of The Wisdom of Whores.
  • Her studies show us how decisions that may appear stupid were arrived at rationally.
  • She has explored the decision making processes of drug addicts and politicians alike.
  • What is the rational approach to a drug that offers some protection from being infected?

Why do rational people do stupid things?

It’s a question we’ve all asked ourselves from time to time, usually forgetting that time we stayed up boozing the night before an exam, or how long we once spent nurturing our love for someone who wasn’t interested.

Those of us who are writers struggle with the question in a more direct way, as we often need our characters to behave in a way that isn’t entirely sensible without making it appear too contrived.

Elizabeth Pisani has spent two decades researching how people catch HIV, which offers a particular view of the question. She described the decisions that lead people to catch HIV in her book, The Wisdom of Whores, and distilled many of the key points in a talk to the 2010 TED conference in Los Angeles:

Subtitles and transcript

Introducing HIV

There are around 37 million people living with HIV in the world today. While treatment is widely available, it still kills over a million people every year by destroying their immune system and letting in a fatal infection. Of the 16 million who are on treatment, most are in sub-Saharan Africa where neither they nor their countries’ healthcare systems could afford it on their own. Their treatment is paid for by the Global Fund, which is largely dependent on donation from the US government. Those people are one mutation away from their infection developing resistance to the treatment and one Congressional decision away from their treatment being withdrawn.

HIV is not an easy virus to catch. Nearly all infections are from sex without a condom or from sharing hypodermic needles. It’s no secret that using a condom and keeping your needle to yourself makes you very unlikely to catch it, yet around two million people still catch it every year. Why, then, don’t people take such basic precautions?

It’s a question that Pisani has engaged with more than most, even among HIV researchers. In The Wisdom of Whores, she describes her decision to make her career in


Scanning electron micrograph of a cell, coloured blue, infected with HIV, coloured yellow (NIAID [CC / Flickr])

AIDS with the humour she shows throughout her TED talk:

Sex, drugs and plenty of squeamish politicians. AIDS was the disease for me.

Satiation now, AIDS later

Much of the decision processes she describes are to do with the fact that HIV spends years, sometimes decades, chipping away at the immune system before it causes AIDS. It’s a problem that can feel very distant in the face of sexual desire or heroin withdrawal:

HIV’s about sex and drugs, and if there are two things that make human beings a little bit irrational, they are erections and addiction.

Pisani’s dissection of the decisions of Indonesian heroin addicts show that rational decisions leading to bad places drive the decisions of policy makers as much as they drive the decisions of addicts. The addicts know that sharing needles is dangerous and they know where to get clean needles. The problem is that voters often prefer politicians to take a hard line against drug users than to spend their taxes on helping them. Consequently, the law was written so that possession of a needle was sufficient evidence for a ten year sentence for drug use.

The law gives the addicts strong incentive not to use the needle exchange program, so they end up sharing needles. Even from the perspective of avoiding HIV, that decision is rational. If they go to prison, they will still be addicted but won’t be able to get hold of clean needles, so they will almost certainly be infected before they come out. Sharing a


Used needles at an exchange program for heroin addicts in Puerto Rico (liza morales [CC / Flickr])

needle on the street carries the same risk of being infected with HIV, but less risk of going to prison.

If you’re thinking that the solution is that they should just give up on heroin, you’re underestimating the power of addiction.

The limits of vulgarity

One of the more successful programs to contain an HIV outbreak was implemented by Margaret Thatcher’s government in 1980s Britain, very much against the ideology of the Conservative party she led. Most British people with HIV were either drug addicts or gay men. Neither group was exactly beloved of conservative voters. Although the laws against men having sex with men were repealed in England and Wales in 1967, Scotland only followed suit in 1980 and the homosexual age of consent was only brought in line with the heterosexual age of consent in 2000. HIV appeared at a time when gay Britain was still very much in the closet.

Yet the government pursued an aggressive program of needle exchange programs and ‘shooting galleries’, where drug users could inject with clean needles while the police turned a blind eye. They also developed a public information campaign that shocked the sensibilities of a country that still treated sex as something to be kept behind closed doors, preferably while drunk.


The Right Honourable Lord Fowler in 2011 (Web Master [CC / Flickr])

It was a rare triumph of rationality over doctrine in policy making.

Norman Fowler, the Health Secretary at the time, deserves much of the credit for pushing through a television campaign that refused to sacrifice clarity for the sake of propriety. The explicit nature of some of the material was not universally appreciated, as revealed by cabinet papers declassified this year, and discussed by a panel including Fowler himself in the annual New Year podcast on papers declassified under the twenty year act.

The comments of the Chancellor, Lord Hailsham, drip with offended sensibilities:

I am convinced there must be some limit to vulgarity and illiteracy. Could they not use the literate, ‘sexual intercourse’. If that is thought to be too narrow, then why not ‘sexual relations’ or ‘physical sexual practices’ but not ‘sex’ or still worse, ‘having sex’.

If Hailsham regarded it is practically pornographic to talk about ‘having sex’, we can only speculate as to his reaction to televised instructions for condom use.

Money talks while compassion only whispers

Returning to the question of rationality, why was the British establishment willing to put aside its distaste for the sake of people it rarely concerns itself with while the Indonesian government pushes the same people toward HIV infection in the name of getting tough on drugs?

Pisani suggests that Thatcher gritted her teeth and gave Fowler the nod because:

She ran a country that had a national health service. So, if she didn’t invest in effective prevention, she was going to have pick up the costs of treatment later on, and obviously those are much higher.

While HIV was restricted to a small number of people in identifiable groups, there was an opportunity to contain it. If the government had taken no action, it would have infected more gay men and drug users, which would have brought a cost to the health service in itself. Because there are bisexual men and because drug users have relationships with

L0052059 An aeroplane in the sky inside which are people wearing

Education leaflet circulated in the UK (Wellcome Images [CC / Flickr])

people who aren’t drug users, it wouldn’t be long before it spread beyond the niche groups and became a large-scale epidemic.

Describing it in epidemiological terms feels rather sterile, so we shouldn’t lose sight of the fact that with no treatment available at the time, we’re talking about people dying a very unpleasant death decades before their time. Perhaps more persuasive to the government of the day was that they would be doing it on the National Health Service’s budget.

So Thatcher and Fowler slapped the lid on the outbreak in the face of the grinding teeth of some of their cabinet colleagues. They were being no more or less rational than the Indonesian government’s policy, and no more or less compassionate. Both governments followed a policy that makes sense in the context of the country that elected them.

Enter Truvada

Since Pisani’s TED talk, a new approach to prevention has appeared in the form of Truvada, a combination of two drugs that are usually used to treat HIV. Last year saw a great deal of excitement in the media when a British study showed that Truvada reduced the infection rate by 85% among ‘MSM’.

For those fortunate enough not to be initiated into the wonderful world of epidemiology acronyms, MSM are men who have sex with men. The term is used because not every man who has sex with other men regards himself as gay.


Demonstration in London, 2015, calling for Truvada to be available on the National Health Service (Jasn [CC / Flickr])

Demonstration in London, 2015, calling for Truvada to be available on the National Health Service (Jasn [CC / Flickr])

There were even calls for Truvada to be supplied through the National Health Service, notably in The Guardian, often a strident advocate on gay issues. The columns of Owen Jones and Zach Stafford capture the enthusiasm for Truvada among its supporters.

Rational advocacy

So is it rational to take Truvada?

As usual, media reporting of the study tended to focus on the latest press release rather than considering context. For a start, we can reduce infection by the same amount by using condoms, which don’t cost £3,000 ($4,300) a year or make anyone nauseous unless they are using them very wrong.

For another thing, other studies on Truvada have not shown such impressive results. The largest study on MSM to date, which was carried out in several different countries, only showed a 44% drop in infection rates, which is considerably less impressive.

A further problem was shown by studies on straight people in Botswana and another in Kenya and Uganda. Among the people taking Truvada who did get infected, several were infected with a virus that was resistant to the drugs contained in Truvada. That means that those people, and anyone else they have infected, have already lost one of the few treatment options open to them.

It’s not time to throw the condoms away yet.

So were Jones and Stafford being irrational when they didn’t mention these problems? Probably not, because whatever the problems with Truvada, the combination of Truvada and condoms is more protective than condoms alone and for someone who refuses to use a condom, Truvada is better than nothing. Jones and Stafford were writing opinion pieces, not journalistic articles, and they are both openly advocating for Truvada. A wise advocate


Mosaic of Pope Benedict, made with the most effective protection against HIV (Robert Elyov [CC / Flickr])

doesn’t give a potential naysayer anything to seize on. The unfortunate consequence of their rational approach to advocacy is that they may be read as describing Truvada as a panacea, which goes a long way beyond the evidence.

Rational stupidity

Returning to the issue of rational stupidity, Pisani has shown us that prioritising an immediate desire over a possible long term consequence is not necessarily irrational, and that muddled policy making can discourage good decisions. It’s something for all of us to bear in mind as writers, voters and in our personal lives.

Truvada offers an opportunity to see where rationality leads. Should it be recommended to protect against HIV? If so, who should pay the £3,000 per year? Please share your thoughts in the comments.

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Posted in Greater minds, Wednesday Pontification

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