90 pounds and the truth

May 15, 2006 -- This week's Newsweek had a very long, admiring piece about Dr. Peter Piot, the Belgian director of the United Nations' Joint Program on HIV/AIDS (UNAIDS). Geoffrey Cowley's "The Life of a Virus Hunter" uses the story of Piot's 25 years fighting AIDS to examine the global response to the disease over that period. The narrative is driven by the efforts and expertise of prominent physicians like Piot, reinforcing the prevailing sense that virtually all clinical and policy leadership on AIDS flows from them. But the piece also devotes most of its excellent first two paragraphs to telling how, two decades ago, Kenyan nurse Elizabeth Ngugi first pioneered programs that empowered poor Nairobi sex workers to adopt safer sex practices. Ngugi's methods drastically reduced HIV transmission, preventing thousands of infections there each year, and inspired rising star Piot to take her ideas worldwide. Ngugi is now a doctorally-prepared member of the community health faculty at the University of Nairobi, and a leader in AIDS care who has been indispensable to international AIDS research for years. One 2000 science magazine profile dubbed her "the ambassador of research" for her work in connecting scholars with poor communities. Yet the Newsweek piece presents her only as "an ebullient, 90-pound nurse named Elizabeth Ngugi." Of course, many mainstream stories would have given her no credit at all. So we thank Cowley, Newsweek, and, on the assumption that he is ultimately responsible for the inclusion of Ngugi, Dr. Piot. And we hope to soon see an equally massive piece about Dr. Ngugi in a national U.S. news magazine.

The Newsweek article describes a brief stopover Piot recently made in Nairobi on his way to a meeting in Rwanda to escort some "dignitaries" on a week of "official visits" to two nations. The piece notes that the "man charged with steering the global response" to AIDS had "come home to a place where he learned how to fight it." Specifically, that's Nairobi's "industrial slum" Majengo, a district of mud huts and open-air markets where "women sell sex for pennies." A small clinic for sexually transmitted diseases in Majengo has reportedly been a "seedbed of discovery" for two decades. There, the piece says, researchers first realized that HIV was spreading in East Africa, that circumcision and STD treatment could slow it, and that some people are essentially immune to the AIDS virus.

But "[m]ost important," the piece says, Majengo is where Ngugi "showed the world how to turn mere victims into advocates for health." In the early 1980's, the district's 2,000 sex workers shunned its new clinic, not even seeking free treatment for STDs, after years of being "demeaned by imperious doctors." The workers also saw little reason to "push condoms on their clients," since the men would simply take their money next door. Ngugi went to the sex workers with a message that the customers would consent to safer sex if the sex workers presented a united front. As Piot "embraces old friends" in Majengo, Ngugi explains:

I walked in the mud and I talked with them in the alleys where they work. I said, "Hey! Do you have a problem with sexually transmitted diseases? We are here! We won't judge you. You are children of God." ... You can't just tell people to make better choices. You have to give them the power and the tools.

The piece notes that "experience proved her right," as condom use shot from 4 percent to more than 90 percent, preventing "some 6,000 to 10,000 new HIV infections every year since." Piot was reportedly "there when it happened, and the experience informs his vision" as UNAIDS director. He stresses that local communities can and must take control of the problem, especially today, when, despite the existence of potent drug cocktails to treat the disease, 40 million worldwide are HIV-positive, and each year five million become HIV-positive and three million die of AIDS, 90 percent of them in developing nations.

The remainder of the piece is the story of Piot's career--it actually says "[t]his is his story"--interspersed with notes on the shifting state of the global AIDS response, from Reagan era denial to post-millennium initiatives to increase the availability of drugs. This is a standard physician-driven account, with extensive quotes from Piot and other physicians who have played roles in high-level efforts to combat the disease since the 1980's, but nothing more from Ngugi or any other nurse. The piece does circle back subtly at the very end, where we find Piot musing at a Rwandan hotel bar that "things are changing" all over Africa, as people are "feeling less helpless and ashamed" about the disease, and communities are "standing up to take their destinies in hand," an energy that, combined with developed world resources, could result in "tremendous progress." The piece concludes: "If it can happen in Majengo, it can happen anywhere."

But it didn't just "happen." Ngugi pushed to make it happen in the face of huge odds. The piece's first two paragraphs reveal an extraordinary patient advocate overcoming her society's social constraints--a female nurse challenging the approach of physicians to an ostracized community--to achieve results that appear to have led to tens of thousands of saved lives in Nairobi, and countless others worldwide. Of course, it seems unlikely that Ngugi would have received any attention had the esteemed Piot not made it a point to take the reporter to her clinic and (we assume) highlight her achievements. Casting no aspersions on Dr. Piot, this seems like a classic story: a female African nurse has a great idea and makes it work locally, and a white male European physician then adopts and spreads it, getting most of the glory. Even the discussion of Ngugi benefits Piot, since his appreciation for her doubtless makes him seem even more impressive to the average reader; the great white physician even learns from the locals.

The piece might have let readers know that Ngugi is, in fact, a globally recognized community health and AIDS care leader with a doctorate. That might have complicated the "earthy wisdom from a native" theme, but it would have presented a better picture of nursing and helped the Ngugis of the future. Ngugi's achievements are awesome, but they are also exactly what nurses are trained to do. If readers understood that, they might see what the profession could do if it received the resources its core philosophy justifies.

For the record, Dr. Elizabeth Ngugi is on the faculty of the Department of Community Health at the University of Nairobi. Her research focuses on the role of social and cultural behavior in sexually transmitted diseases. She has served as chair of the National Nurses Association of Kenya, she is a founding member of the Society for Women and AIDS in Africa, and she is a member of numerous international health organizations. She received her doctorate in social work from the University of Washington, Seattle. A short June 2000 profile of Ngugi in Science Magazine, Jon Cohen's "An Ambassador of Research," explained that she

plays a role that is crucial for many AIDS projects throughout Africa--but one that seldom receives credit in scientific circles. ... Ngugi connects ostracized communities that have little education and even less money to an international team of AIDS scientists that would like to follow them over time, learning the most intimate details about their sexual practices, their jobs and families, and, of course, their diseases.

A leading researcher in this group, the University of Manitoba's Frank Plummer, calls Ngugi "a public health phenomenon" and says the group's groundbreaking research would have been "impossible" without her. In exchange for participating in her studies, Ngugi offers prostitutes advanced care for STDs, free condoms, "checkups by top-notch doctors," and "news from the front" about the state of AIDS care. The Cohen piece finds Ngugi in a downtown brothel, surrounded by a dozen prostitutes, discussing the benefits of the female condom. One prostitute says the sex workers feel "great love" for Ngugi, and notes that she "would never be alive today without her." In October 2004, Ngugi was recognized as the United Nations in Kenya Person of the Year (above) for her work in the prevention of the spread of HIV/AIDS and other STDs.

Not bad for a "90-pound nurse."

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