"People do stupid things. That's what spreads HIV." This was a headline in a U.K. newspaper, The Guardian, not that long ago. I'm curious, show of hands, who agrees with it? Well, one or two brave souls.
«A xente fai parvadas. Iso é o que propaga o VIH.» Foi titular nun xornal do Reino Unido, The Guardian, non hai moito tempo. Teño curiosidade. Levantade a man, quen está de acordo con el? Ben, un ou dous valentes.
This is actually a direct quote from an epidemiologist who's been in field of HIV for 15 years, worked on four continents, and you're looking at her.
De feito, é a cita dunha epidemióloga que leva 15 anos no campo do VIH, traballou en catro continentes e estades a mirar para ela.
And I am now going to argue that this is only half true. People do get HIV because they do stupid things, but most of them are doing stupid things for perfectly rational reasons. Now, "rational" is the dominant paradigm in public health, and if you put your public health nerd glasses on, you'll see that if we give people the information that they need about what's good for them and what's bad for them, if you give them the services that they can use to act on that information, and a little bit of motivation, people will make rational decisions and live long and healthy lives. Wonderful.
E agora vou razoar por que isto é unha media verdade. As persoas pillan VIH porque fan parvadas, pero a maioría delas fan parvadas por razóns perfectamente racionais. O «racional» é o paradigma principal en saúde pública. Se poñede os lentes de friki da saúde pública, veredes que se se lle dá ás persoas a información que necesitan para saber o que é bo ou malo para elas, se se lles dan os servizos para actuar en consecuencia e un pouco de motivación, tomarán decisións racionais e vivirán vidas longas e saudables. Marabilloso.
That's slightly problematic for me because I work in HIV, and although I'm sure you all know that HIV is about poverty and gender inequality, and if you were at TED '07 it's about coffee prices ... Actually, 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.
Isto é un pouquiño problemático para min porque traballo co VIH e, aínda que seguro que todos sabedes que o VIH ten que ver coa pobreza e a desigualdade de xénero, e se estivestes na TED′07 tenq ue ver cos prezos do café... En realidade, o VIH ten que ver co sexo e as drogas e, se hai dúas cousas que fan aos seres humanos un chisco irracionais, son as ereccións e as adiccións.
(Laughter)
(Risas)
So, let's start with what's rational for an addict. Now, I remember speaking to an Indonesian friend of mine, Frankie. We were having lunch and he was telling me about when he was in jail in Bali for a drug injection. It was someone's birthday, and they had very kindly smuggled some heroin into jail, and he was very generously sharing it out with all of his colleagues. And so everyone lined up, all the smackheads in a row, and the guy whose birthday it was filled up the fit, and he went down and started injecting people. So he injects the first guy, and then he's wiping the needle on his shirt, and he injects the next guy. And Frankie says, "I'm number 22 in line, and I can see the needle coming down towards me, and there is blood all over the place. It's getting blunter and blunter. And a small part of my brain is thinking, 'That is so gross and really dangerous,' but most of my brain is thinking, 'Please let there be some smack left by the time it gets to me. Please let there be some left.'" And then, telling me this story, Frankie said, "You know ... God, drugs really make you stupid."
Así que imos comezar por ver que é racional para un adicto. Recordo unha conversa co meu amigo indonesio Frankie. Estabamos a xantar mentres me falaba de cando estivo no cárcere en Bali por consumo de drogas. Era o aniversario de alguén e, moi amablemente, meteran unha pouca heroína no cárcere e estaba a repartila xenerosamente con todos os seus colegas, así que fixeron unha fila, todos os xonquis en liña, e o rapaz que estaba de aniversario encheu a xiringa e empezou a inxectar a xente. Inxecta o primeiro rapaz, limpa a agulla coa camisa e inxecta o seguinte. E Frankie di: «Son o número 22 na fila e podo ver a xiringa vindo cara a min, e hai sangue por todas partes. A agulla estase desafiando e unha pequena parte do meu cerebro pensa: “Isto é noxento e moi perigoso”. Pero a maior parte do meu cerebro di: “por favor, deixade algo de cabalo para cando chegue a miña vez. Por favor, deixade un pouco”». E entón, contándome esta historia, Frankie dixo: «Xa sabes... Meu deus, as drogas fante moi estúpido».
And, you know, you can't fault him for accuracy. But, actually, Frankie, at that time, was a heroin addict and he was in jail. So his choice was either to accept that dirty needle or not to get high. And if there's one place you really want to get high, it's when you're in jail.
E tiña toda a razón. Pero o certo é que, nese momento, Frankie era heroinómano e estaba no cárcere, así que a súa elección estaba entre aceptar esa xiringa ou non colocarse e, se hai un sitio onde queres colocarte, é no cárcere.
But I'm a scientist and I don't like to make data out of anecdotes, so let's look at some data. We talked to 600 drug addicts in three cities in Indonesia, and we said, "Well, do you know how you get HIV?" "Oh yeah, by sharing needles." I mean, nearly 100 percent. Yeah, by sharing needles. And, "Do you know where you can get a clean needle at a price you can afford to avoid that?" "Oh yeah." Hundred percent. "We're smackheads; we know where to get clean needles." "So are you carrying a needle?" We're actually interviewing people on the street, in the places where they're hanging out and taking drugs. "Are you carrying clean needles?" One in four, maximum. So no surprises then that the proportion that actually used clean needles every time they injected in the last week is just about one in 10, and the other nine in 10 are sharing.
Porén, son científica e non me gusta obter datos a partir de anécdotas, así que vexamos algúns datos. Falamos con 600 drogadictos en tres cidades de Indonesia e dixemos: «Sabedes onde pillastes o VIH?». «Ah, si, compartindo xiringas». Case o 100 %. «Si, compartindo xiringas». «Sabedes onde conseguir xiringas limpas a un prezo alcanzable para evitar iso?» «Ah, si». O 100 %. «Somos xonquis; sabemos onde conseguir xiringas limpas». «Entón, levades con vós unha xiringa?» Estamos a entrevistar a xente na rúa, en lugares onde quedan para drogarse. «Tedes xiringas limpas?» Un de cada catro, máximo. Non foi unha sorpresa descubrir que a proporción que usara agullas limpas cada vez que se inxectara na última semana era de un de cada 10, e que os outros nove estaban a compartilas.
So you've got this massive mismatch; everyone knows that if they share they're going to get HIV, but they're all sharing anyway. So what's that about? Is it like you get a better high if you share or something? We asked that to a junkie and they're like, "Are you nuts?" You don't want to share a needle anymore than you want to share a toothbrush even with someone you're sleeping with. There's just kind of an ick factor there. "No, no. We share needles because we don't want to go to jail." So, in Indonesia at this time, if you were carrying a needle and the cops rounded you up, they could put you into jail. And that changes the equation slightly, doesn't it? Because your choice now is either I use my own needle now, or I could share a needle now and get a disease that's going to possibly kill me 10 years from now, or I could use my own needle now and go to jail tomorrow. And while junkies think that it's a really bad idea to expose themselves to HIV, they think it's a much worse idea to spend the next year in jail where they'll probably end up in Frankie's situation and expose themselves to HIV anyway. So, suddenly it becomes perfectly rational to share needles.
Daquela, existe esta tremenda discordancia; todo o mundo sabe que se comparte xiringas vai pillar VIH, pero, aínda así, compárteas. De que vai isto? Cren que ao compartir colócanse máis? Preguntámosllo a un xonqui. Respondeu: «Estades tolos?». Non queres compartir xiringa igual que non compartirías cepillo de dentes nin coa persoa coa que te estás deitando. Dá noxo. «Non, non. Compartimos xiringas porque non queremos acabar no cárcere». En Indonesia, nese momento, se levabas enriba unha xiringa e a poli te cachaba, podían meterte no cárcere. E iso cambia un chisco a ecuación, porque agora tes dúas opcións: comparto unha xiringa agora e pillo unha enfermidade que posiblemente me mate dentro de 10 anos ou podo usar a miña propia xiringa hoxe e ir ao cárcere mañá mesmo. Aínda que os xonquis pensan que é malísima idea exporse ao VIH, cren que é unha idea moito peor pasar o próximo ano no cárcere, onde probablemente acaben coma Frankie e se expoñan ao VIH de todas maneiras. De súpeto, compartir xiringas convértese en algo totalmente racional.
Now, let's look at it from a policy maker's point of view. This is a really easy problem. For once, your incentives are aligned. We've got what's rational for public health. You want people to use clean needles -- and junkies want to use clean needles. So we could make this problem go away simply by making clean needles universally available and taking away the fear of arrest. Now, the first person to figure that out and do something about it on a national scale was that well-known, bleeding heart liberal Margaret Thatcher. And she put in the world's first national needle exchange program, and other countries followed suit: Australia, The Netherlands and few others. And in all of those countries, you can see, not more than four percent of injectors ever became infected with HIV.
Agora, mirémolo dende o punto de vista de quen fan as leis. É un problema fácil de resolver. Por unha vez, os teus incentivos coinciden. Por unha banda, temos o que é racional para a saúde pública. Queremos que a xente use xiringas limpas e os xonquis queren usar agullas limpas, así que poderíamos desfacernos deste problema facendo que as xiringas limpas estean dispoñibles universalmente e eliminando o medo ao arresto. A primeira persoa en darse de conta disto e facer algo a escala nacional foi a célebre e tan compasiva política liberal Margaret Thatcher. Puxo en marcha o primeiro sistema nacional de troco de xiringas do mundo, e outros países foron detrás: Australia, os Países Baixos e algún máis. En todos eses países, podemos ver que só o 4 % dos adictos
Now, places that didn't do this -- New York City for example,
contraeron o VIH nalgún momento.
Moscow, Jakarta -- we're talking, at its peak, one in two injectors infected with this fatal disease. Now, Margaret Thatcher didn't do this because she has any great love for junkies. She did it 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. So she was making a politically rational decision. Now, if I take out my public health nerd glasses here and look at these data, it seems like a no-brainer, doesn't it? But in this country, where the government apparently does not feel compelled to provide health care for citizens, (Laughter) we've taken a very different approach. So what we've been doing in the United States is reviewing the data -- endlessly reviewing the data. So, these are reviews of hundreds of studies by all the big muckety-mucks of the scientific pantheon in the United States, and these are the studies that show needle programs are effective -- quite a lot of them. Now, the ones that show that needle programs aren't effective -- you think that's one of these annoying dynamic slides and I'm going to press my dongle and the rest of it's going to come up, but no -- that's the whole slide.
En lugares onde non se levou a cabo (Nova York, Moscova, Iacarta), nos peores momentos un de cada dous inxectores infectábanse desta letal enfermidade. Margaret Thatcher non fixo isto polo seu amor aos xonquis; fíxoo porque gobernaba un país que tiña un sistema nacional de saúde, así que, se non investía nunha prevención efectiva, ía ter que pagar os custos do tratamento máis adiante e, obviamente, sairía moito máis caro. Estaba a tomar unha decisión politicamente racional. Se collo os meus lentes de friki da saúde pública e miro para estes datos... Penso que, máis claro, auga, non? Pero neste país, onde aparentemente o goberno non se sente obrigado a dar atención sanitaria aos cidadáns, [Risas] abordamos o problema dun xeito diferente. Así que o que estamos a facer nos Estados Unidos é revisar os datos sen parar. Esta é a análise de centos de estudos realizados polos máis ilustres científicos dos Estados Unidos e estes son os moitísimos estudos que amosan que os programas de troco de xiringas son efectivos. Os que conclúen que os programas non son efectivos... Pensaredes que estarán nunha desas diapositivas dinámicas insufribles e que vou premer no botón e van aparecer, pero non: esta é a diapositiva completa.
(Laughter)
(Risas)
There is nothing on the other side. So, completely irrational, you would think. Except that, wait a minute, politicians are rational, too, and they're responding to what they think the voters want. So what we see is that voters respond very well to things like this and not quite so well to things like this.
Non hai nada ao outro lado. Así que pensaredes: «totalmente irracional». Pero os políticos tamén son racionais e responden ao que cren que queren os seus votantes. Así que o que vemos é que os votantes responden moi ben a cousas así, pero non tan ben a cousas así.
(Laughter)
(Risas)
So it becomes quite rational to deny services to injectors. Now let's talk about sex. Are we any more rational about sex? Well, I'm not even going to address the clearly irrational positions of people like the Catholic Church, who think somehow that if you give out condoms, everyone's going to run out and have sex. I don't know if Pope Benedict watches TEDTalks online, but if you do, I've got news for you Benedict -- I carry condoms all the time and I never get laid. (Laughter) (Applause) It's not that easy! Here, maybe you'll have better luck.
Rexeitar dar servizos aos heroinómanos convértese en algo bastante racional. Agora falemos sobre sexo. Somos máis racionais co tema do sexo? Nin sequera vou mencionar a postura claramente irracional de colectivos coma a Igrexa Católica, que pensa que, se alguén reparte condóns, todo o mundo liscará a ter sexo. Non sei se o papa Bieito ve TEDTalks en liña, pero, se o fas, teño boas novas para ti, Bieito: sempre levo condóns enriba e nunca consigo botar un foguete. (Risas) (Aplausos) Non é tan doado! Ao mellor vós tedes máis sorte ca min.
(Applause)
(Aplausos)
Okay, seriously, HIV is actually not that easy to transmit sexually. So, it depends on how much virus there is in your blood and in your body fluids. And what we've got is a very, very high level of virus right at the beginning when you're first infected, then you start making antibodies, and then it bumps along at quite low levels for a long time -- 10 or 12 years -- you have spikes if you get another sexually transmitted infection. But basically, nothing much is going on until you start to get symptomatic AIDS, and by that stage, you're not looking great, you're not feeling great, you're not having that much sex.
Non, en serio. Transmitir o VIH por vía sexual, realmente, non é tan sinxelo. Depende de canto virus haxa no teu sangue e nos teus fluídos corporais. Temos niveis altísimos de virus nada máis ser infectados por primeira vez, logo comezas a producir anticorpos e van tirando cara niveis bastante baixos durante moito tempo (10 ou 12 anos) con picos se te volves contaxiar por vía sexual. Pero en xeral, non pasa nada ata que aparecen os síntomas da sida, pero, nesa etapa, non es atractivo, non te atopas ben, e non tes moito sexo.
So the sexual transmission of HIV is essentially determined by how many partners you have in these very short spaces of time when you have peak viremia. Now, this makes people crazy because it means that you have to talk about some groups having more sexual partners in shorter spaces of time than other groups, and that's considered stigmatizing. I've always been a bit curious about that because I think stigma is a bad thing, whereas lots of sex is quite a good thing, but we'll leave that be. The truth is that 20 years of very good research have shown us that there are groups that are more likely to turnover large numbers of partners in a short space of time. And those groups are, globally, people who sell sex and their more regular partners. They are gay men on the party scene who have, on average, three times more partners than straight people on the party scene. And they are heterosexuals who come from countries that have traditions of polygamy and relatively high levels of female autonomy, and almost all of those countries are in east or southern Africa. And that is reflected in the epidemic that we have today.
Así que a transmisión sexual do VIH está fundamentalmente determinada por cantas parellas tes neste curto espazo de tempo cando a viremia acada o seu pico. Isto tolea á xente, porque implica ter que falar de que algúns grupos teñen máis parellas sexuais en pouco tempo ca outros, e iso causa estigma. Sempre tiven moita curiosidade sobre iso porque penso que o estigma é malo, mentres que ter moito sexo é boa cousa, pero deixémolo estar. A verdade é que 20 anos de moi boa investigación amosaron que hai grupos que tenden a cambiar moitas veces de parella nun curto espazo de tempo. A nivel mundial, eses grupos son as traballadoras sexuais e as súas parellas máis frecuentes. Tamén aparecen os homes gais de esmorga, que, de media, teñen 3 veces máis parellas que as persoas heterosexuais de esmorga. E hai heterosexuais que proceden de países con tradición de poligamia e bastante liberdade das mulleres, e case todos eses países están no leste ou no sur de África. E iso vese reflectido na epidemia actual. Podedes ver estas cifras terroríficas de África.
You can see these horrifying figures from Africa. These are all countries in southern Africa where between one in seven, and one in three of all adults, are infected with HIV. Now, in the rest of the world, we've got basically nothing going on in the general population -- very, very low levels -- but we have extraordinarily high levels of HIV in these other populations who are at highest risk: drug injectors, sex workers and gay men. And you'll note, that's the local data from Los Angeles: 25 percent prevalence among gay men. Of course, you can't get HIV just by having unprotected sex. You can only HIV by having unprotected sex with a positive person.
Todos estes son países do sur de África onde entre un de cada sete, e un de cada tres adultos, están infectados co VIH. No resto do mundo, apenas aparecen casos na poboación xeral (son niveis moi baixiños), pero temos niveis altísimos de VIH nestas outras poboacións de maior risco: inxectores de droga, traballadoras sexuais e homes gais. Estes son os datos locais dos Ánxeles: 25 % de prevalencia nos homes gais. Por suposto, non pillas o VIH só por ter sexo sen protección. Só podes pillar o VIH tendo sexo sen protección cunha persoa positiva.
In most of the world, these few prevention failures notwithstanding, we are actually doing quite well these days in commercial sex: condom use rates are between 80 and 100 percent in commercial sex in most countries. And, again, it's because of an alignment of the incentives. What's rational for public health is also rational for individual sex workers because it's really bad for business to have another STI. No one wants it. And, actually, clients don't want to go home with a drip either. So essentially, you're able to achieve quite high rates of condom use in commercial sex.
Na maior parte do mundo, esta prevención fracasa, aínda que, en realidade estamos a facelo bastante ben no ambito d prostitución: os índices de uso de condón están entre o 80 e o 100 % na prostitución na maioría dos países. Outra vez, é grazas ao aliñamento de incentivos. O que é racional para a saúde pública, tamén é racional para as prostitutas, porque é moi malo para o negocio ter outra ITS. Ninguén o quere. E os clientes tampouco queren volver a casa cunha vía posta. Así que na prostitución é sinxelo acadar altas taxas de uso de condón.
But in "intimate" relations it's much more difficult because, with your wife or your boyfriend or someone that you hope might turn into one of those things, we have this illusion of romance and trust and intimacy, and nothing is quite so unromantic as the, "My condom or yours, darling?" question. So in the face of that, you really need quite a strong incentive to use condoms.
Pero nas relacións «íntimas» é moito máis difícil porque coa túa muller ou co teu mozo ou con quen che gustaría que se convertera niso, temos ese delirio de romance, confianza e intimidade, e non hai nada menos romántico que a pregunta de: «O teu condón ou o meu, querido?» Fronte a iso, necesitas un incentivo moi forte para usar condón.
This, for example, this gentleman is called Joseph. He's from Haiti and he has AIDS. And he's probably not having a lot of sex right now, but he is a reminder in the population, of why you might want to be using condoms. This is also in Haiti and is a reminder of why you might want to be having sex, perhaps. Now, funnily enough, this is also Joseph after six months on antiretroviral treatment. Not for nothing do we call it the Lazarus Effect. But it is changing the equation of what's rational in sexual decision-making. So, what we've got -- some people say, "Oh, it doesn't matter very much because, actually, treatment is effective prevention because it lowers your viral load and therefore makes it more difficult to transmit HIV." So, if you look at the viremia thing again, if you do start treatment when you're sick, well, what happens? Your viral load comes down. But compared to what? What happens if you're not on treatment? Well, you die, so your viral load goes to zero. And all of this green stuff here, including the spikes -- which are because you couldn't get to the pharmacy, or you ran out of drugs, or you went on a three day party binge and forgot to take your drugs, or because you've started to get resistance, or whatever -- all of that is virus that wouldn't be out there, except for treatment.
Este é un señor chamado Joseph. É de Haití e ten a sida. Probablemente non estea a ter moito sexo agora mesmo, pero é un recordatorio para a poboación de que hai que usar condón. Isto tamén é en Haití e, se cadra, é un recordatorio de por que quererías ter sexo. (Risas) Sorprendentemente, este tamén é Joseph logo de 6 meses con tratamento antirretroviral. Con razón se lle chama Efecto Lázaro. Pero está a mudar a ecuación do que é racional ao tomar decisións sexuais. Achamos que algunha xente di: «Non importa moito porque o tratamento é unha prevención efectiva, porque baixa a carga viral e, por tanto, fai máis difícil que se transmita o VIH». Miremos a gráfica da viremia outra vez. Se comezas o tratamento ao enfermar, que acontece? A túa carga viral diminúe. Pero comparado con que? Que ocorre se non te tratas? Morres, así que a carga viral baixa a cero. E isto en verde, incluíndo os picos, que ocorren porque non puideches ir á farmacia, quedaches sen menciñas ou fuches de troula tres días seguidos e esqueciches tomar os medicamentos ou porque están xurdindo resistencias ou o que sexa, todo iso son virus que non estarían por aí se non fose polo tratamento.
Now, am I saying, "Oh, well, great prevention strategy. Let's just stop treating people." Of course not, of course not. We need to expand antiretroviral treatment as much as we can. But what I am doing is calling into question those people who say that more treatment is all the prevention we need. That's simply not necessarily true, and I think we can learn a lot from the experience of gay men in rich countries where treatment has been widely available for going on 15 years now. And what we've seen is that, actually, condom use rates, which were very, very high -- the gay community responded very rapidly to HIV, with extremely little help from public health nerds, I would say -- that condom use rate has come down dramatically since treatment for two reasons really: One is the assumption of, "Oh well, if he's infected, he's probably on meds, and his viral load's going to be low, so I'm pretty safe."
Estou dicindo «boa estratexia de prevención. Deixemos de tratar á xente». Claro que non. Hai que espallar os antirretrovirais todo o que poidamos. Pero o que estou a facer é pór en dúbida a aqueles que din que máis tratamento é toda a prevención que necesitamos. Isto non é necesariamente verdade e podemos aprender moito da experiencia dos homes gais nos países ricos, onde o tratamento leva estando dispoñible dende hai 15 anos e o que estamos vendo é que os índices de uso de condón, que foron moi altos (a comunidade gai respondeu rapidísimo ao VIH con moi pouquiña axuda dos frikis da Saúde Pública), o uso de condón diminuíu moitísimo desde que existe tratamento por dúas razóns: unha é asumir que, se alguén está infectado, tomará medicamentos e a súa carga viral será baixa, así que estamos a salvo.
And the other thing is that people are simply not as scared of HIV as they were of AIDS, and rightly so. AIDS was a disfiguring disease that killed you, and HIV is an invisible virus that makes you take a pill every day. And that's boring, but is it as boring as having to use a condom every time you have sex, no matter how drunk you are, no matter how many poppers you've taken, whatever? If we look at the data, we can see that the answer to that question is, mmm.
A outra razón é que a xente non lle ten tanto medo ao VIH coma lle tiña á sida, e con razón. A sida era unha enfermidade desfiguradora que adoitaba matarte e o VIH é un virus invisible que che fai tomar unha pastilla cada día. E iso é aburrido, pero tan aburrido coma ter que usar condón cada vez que tes sexo, sen importar o bébedo que esteas ou a cantidade de <i>popper </i>que tomaras? Se miramos os datos, podemos ver que a resposta a esta pregunta é «mmm...». Estes datos son de Escocia.
So these are data from Scotland. You see the peak in drug injectors before they started the national needle exchange program. Then it came way down. And both in heterosexuals -- mostly in commercial sex -- and in drug users, you've really got nothing much going on after treatment begins, and that's because of that alignment of incentives that I talked about earlier. But in gay men, you've got quite a dramatic rise starting three or four years after treatment became widely available. This is of new infections.
Podedes ver o pico de inxectores de droga antes de existir o programa nacional de troco de xiringas. Logo baixou. E tanto en heterosexuais (sobre todo na prostitución) coma en drogadictos non cambia moito logo de que empece o tratamento. Isto débese ao aliñamento de incentivos do que falei anteriormente. Pero nos homes gais houbo un enorme aumento tres ou catro anos despois de que o tratamento comezara a estar dispoñible. Isto son as novas infeccións.
What does that mean? It means that the combined effect of being less worried and having more virus out there in the population -- more people living longer, healthier lives, more likely to be getting laid with HIV -- is outweighing the effects of lower viral load, and that's a very worrisome thing. What does it mean? It means we need to be doing more prevention the more treatment we have.
Que significa isto? Que a combinación dunha menor preocupación e a maior presenza do virus na poboación (hai máis xente vivindo vidas máis longas e sas, con maior probabilidade de foder, aínda tendo VIH) está a superar os efectos da baixa carga viral, e é un feito moi preocupante. Isto que significa? Que necesitamos facer máis prevención canto máis tratamento temos.
Is that what's happening? No, and I call it the "compassion conundrum." We've talked a lot about compassion the last couple of days, and what's happening really is that people are unable quite to bring themselves to put in good sexual and reproductive health services for sex workers, unable quite to be giving out needles to junkies. But once they've gone from being transgressive people whose behaviors we don't want to condone to being AIDS victims, we come over all compassionate and buy them incredibly expensive drugs for the rest of their lives. It doesn't make any sense from a public health point of view.
É iso o que está a acontecer? Non, e eu chámoo o «enigma da compaixón». Estivemos falando moito de compaixón nestes últimos días, e o que en realidade acontece é que a xente é incapaz de esforzarse en crear bos servizos de saúde sexual e reprodutiva para traballadores sexuais, incapaz de repartir xiringas aos xonquis. Pero cando pasan de ser persoas transgresoras cuxas condutas non queremos consentir a ser vítimas da sida, de súpeto somos compasivos e mercámoslles fármacos carísimos durante o resto da súa vida. Non ten sentido dende o punto de vista da saúde pública.
I want to give what's very nearly the last word to Ines. Ines is a a transgender hooker on the streets of Jakarta; she's a chick with a dick. Why does she do that job? Well, of course, because she's forced into it because she doesn't have any better option, etc., etc. And if we could just teach her to sew and get her a nice job in a factory, all would be well. This is what factory workers earn in an hour in Indonesia: on average, 20 cents. It varies a bit province to province. I do speak to sex workers, 15,000 of them for this particular slide, and this is what sex workers say they earn in an hour. So it's not a great job, but for a lot of people it really is quite a rational choice. Okay, Ines.
Por último, quero cederlle a palabra a Ines. Ines é puta transxénero nas rúas de Iacarta; é unha moza con pito. Por que fai ese traballo? Por suposto, porque se ve obrigada, porque non ten outra opción mellor etc. Se puidésemos aprenderlle a coser e darlle un bo traballo nunha fábrica, todo estaría ben. Isto gañan por hora os traballadores dunha factoría en Indonesia: Vinte céntimos, de media. Varía un chisco entre provincias. Falei con 15.000 traballadoras sexuais para esta diapositiva en concreto e isto é o que afirman gañar por hora. Non é un gran traballo, pero para moita xente é unha elección bastante racional. De acordo, Ines.
We've got the tools, the knowledge and the cash, and commitment to preventing HIV too.
Temos as ferramentas, os coñecementos, diñeiro e o compromiso para previr o VIH.
Ines: So why is prevalence still rising? It's all politics. When you get to politics, nothing makes sense.
Ines: Entón por que a prevalencia segue a aumentar? É todo cuestión de política. Cando se trata de política, nada ten sentido.
Elizabeth Pisani: "When you get to politics, nothing makes sense." So, from the point of view of a sex worker, politicians are making no sense. From the point of view of a public health nerd, junkies are doing dumb things. The truth is that everyone has a different rationale. There are as many different ways of being rational as there are human beings on the planet, and that's one of the glories of human existence. But those ways of being rational are not independent of one another, so it's rational for a drug injector to share needles because of a stupid decision that's made by a politician, and it's rational for a politician to make that stupid decision because they're responding to what they think the voters want. But here's the thing: we are the voters. We're not all of them, of course, but TED is a community of opinion leaders. And everyone who's in this room, and everyone who's watching this out there on the web, I think, has a duty to demand of their politicians that we make policy based on scientific evidence and on common sense. It's going to be really hard for us to individually affect what's rational for every Frankie and every Ines out there, but you can at least use your vote to stop politicians doing stupid things that spread HIV.
«Cando se trata de política, nada ten sentido». Dende o punto de vista dunha prostituta, os políticos non teñen sentido. Dende o punto de vista dunha friki da saúde pública, os xonquis fan parvadas. A verdade é que todos teñen unha lóxica diferente. Hai tantas formas de ser racional coma seres humanos hai no planeta, e esa é unha das marabillas da existencia humana. Pero esas formas de ser racional non son independentes entre si, así que é racional para un drogadicto compartir xiringas grazas a unha decisión estúpida tomada por un político, e é racional para o político tomar esa decisión estúpida porque está respondendo ao que cre que os seus votantes queren. Pero aquí está a cousa: nós somos os votantes. Non todos: TED é unha comunidade de líderes de opinión, e todo aquel que está nesta sala e todo aquel que está vendo isto na rede penso que ten o deber de esixirlles aos seus políticos que fagan políticas baseadas na evidencia científica e no sentido común. Vai ser moi complicado para nós influír de forma individual no que é racional por todos os Frankies e Ines que están aí, pero, cando menos, podedes empregar o voso voto para impedir que os políticos fagan parvadas que propaguen o VIH.
Thank you.
Grazas.
(Applause)
(Aplausos)