Sex workers share with other members of the urban poor, a deep distrust of the medical profession. Interviews with women in prostitution in three cities — Bombay, Calcutta and Delhi — and parts of Maharashtra — Kohlapur, Ahmednagar and Yavatmal simultaneously bring out aspects of what are uniquely their experience. This article will look at some of the ethical issues involved in health care and sex work. The first part focuses on the perceived needs of the primary actors, the second on attitudes of health care professionals. Finally, it looks at laws and policies that attempt to redress the situation, often unsuccessfully.

What do sex workers want?

Among the more significant health needs of sex workers are reliable health care systems for themselves and their children, dependable contraception, protection from sexual violence within the profession, and from STDs and AIDS. As a report by National Commission for Women (NCW) recognises, “No woman suffers more discrimination in access to services, whether for health care, fertility regulations or safe abortions as much as women in sex work.” (1)

There is a marked absence of adequate health care facilities in red light areas. As Gita, a sex worker attached to the BMC-HIV/AIDS cell points out, “Private doctors are no good, they charge a lot of money, and the treatment is not always good. Municipal hospitals are cheaper, but sometimes the doctors treat us badly if they realise that we are prostitutes. And I have seen them to be rude and uncaring with AIDS patients.” Despite this, however, Gita prefers government hospitals.

This view is shared by women in other parts of the country. Padma, a brothel keeper in Sonagachi, Calcutta, says that she takes the women in her brothel to the government-run health care centres. “Those in the area who have money go to private doctors because they feel that they might give them better care. But I don’t think so. Even though I don’t lack money, I prefer government clinics, because the doctors are more thorough.”

Primary health centres in red light areas are, however, ill equipped with essential drugs. Sex workers point out that the staff do not come to work regularly. Often, sex workers are forced to pay ‘donations’ or to have sex with the doctors or social workers to get access to some services. The timings are not convenient, as they are not open in the afternoon. (2) Efforts by a Delhi based NGO, Bhartiya Patita Udhar Samiti, to lobby for shifting the timings to suit sex workers have proved unsuccessful.

AIDS prevention is a significant part of the health needs of sex workers. To this end, NGOs such as Bhartiya Patita Udhar Samiti, the Bombay-based BMC – HIV Intervention Unit and the Sexual Health Intervention Programme (SHIP), Calcutta, distribute free or subsidised condoms. However, sex workers often face several problems. The overwhelming focus on condom use to prevent AIDS and STDs does not keep into account the lived realities of women in the profession. It is not always possible for powerless sex workers to insist that the client wears a condom. According to Anju Pawar, community development officer of the BMC Cell which works in the red light areas in Bombay: “We tell women to use condoms with all their clients, but it is not always possible. How can they? If the woman is very young, and the man is aggressive, she can’t refuse him. Also, if the woman is hungry and needs money desperately, she doesn’t dare to insist that the man use a condom.” The BMC-HIV/AIDS Prevention Cell therefore feels that such messages should be targeted at male clients.

However, AIDS is not the only health issue for sex workers. Organisations such as the BMC HIV/AIDS Centre have realised that it is impossible to focus exclusively on AIDS prevention. Manisha, a sex worker working with the Centre, points out that “Sex workers have a host of reproductive tract infections. Seventy five per cent of women practicing the sex trade have some form of STD. White discharge and burning with urination are common health problems, as is TB.” Dr. Kannai Banerjee, attached to the Calcutta Medical College, says that in his experience, reproductive tract infections like genital ulcers and discharge are common among sex workers. There is a high incidence of skin infections, such as scabies, and illnesses like Hepatitis B. In addition, women and children in prostitution are vulnerable to depression, malnutrition and TB.

Attitudes of health care practitioners

As we have seen, many women in prostitution prefer to access public health care services, even though they are inadequate. Dr. Amar Kumar Singh, who works in the health clinic run by SHIP in Sonagachi, feels that to a large extent, NGOs like SHIP are taking over the role of the state as far as providing health care is concerned. “Indian government expenditure on health is only three per cent of the GDP. This is inadequate. So NGOs are forced to take up the burden”.

Well-meaning though many NGOs are, the shifting of responsibility from the state creates an odd situation. The state has a responsibility towards its citizens, and is accountable to them. If its role is declining in the important area of health care, it can only weaken the access of the poor. This gets magnified when it comes to sex workers, who are anyway marginalised socially and legally.

Health-care practitioners are justifiably accused of treating sex workers as ‘carriers’ of STDs and HIV. As a result women in prostitution have been subjected to human rights violations. Doctors have refused to treat women because of fear that they might be carrying the virus. Women from red light areas have been subjected to compulsory testing for HIV. (3)

Lawyers Anand Grover and Priti Patel explain that consent is needed for HIV testing, as it involves removing an individual’s bodily fluids. Compulsory and forced testing is clearly illegal, and violates WHO guidelines. At a 1993 regional workshop organised by WHO attended by Indian representatives, a recommendation was passed that: “Governments should adopt national policies on HIV testing, including confidentiality. There is no medical, or public health rationale for screening or routine testing of specific risk groups or patient groups.”

Significantly, isolating sex workers — as any other group — as high risk groups or ‘vectors’ of infection is clearly unethical, and counterproductive. Recently, there have been two attempts by the Maharashtra state government to pass bills that focus on prostitutes to prevent STDs.

Laws and policies

In 1989, a bill was introduced in the Maharashtra Legislative Assembly entitled, ‘A Bill To Provide for The Regulation and Control of Activities Of Prostitutes And Brothels With a View to Prevent the Growth of Disease Known as Acquired Immunity Deficiency Syndrome (AIDS).” (4) The statement of objects of the bill stated: “The object in bringing this legislation is to prevent and control the growth of the Acquired Immunity Deficiency Syndrome (AIDS) disease. The medical experts have opined that the main cause of this disease is common prostitution.” (Emphasis added). (5) The assumption behind this statement is not borne out by any systematic medical study and reveals a fair amount of bias. The bill does not attribute any responsibility for spreading AIDS to customers visiting brothels. It is the women who are to be subjected to humiliating medical examinations, with or without their informed consent. The notion of informed consent is absent.

Equally brazen is a bill proposed in 1994 by the Government of Maharashtra. The bill enabled the registration of prostitutes under a board constituted by the government. The board would conduct compulsory periodic medical testing for detection of sexually transmitted diseases (STDs). All those found suffering from STDs would be liable to be branded with indelible ink. (6) If such bills are passed, they will legalise wide spread human rights violations against sex workers.

The real danger is that the state and the medical community seem to be overwhelmed by focus on STDs and AIDS prevention in red light areas. Consequently, there is little or no attention paid to other serious health needs. Simultaneously, isolating women in prostitution as ‘vectors’ of infection is not only unethical, it is also counterproductive.

The net result of targeting women in red light areas, as the NCW report elaborates, is that it “increases public and police violence upon them; decreases their ability to assert themselves; allows customers to demand and force unsafe sex upon them; and increases the rate of HIV infection among women, ….customers and the family of the customers.” In addition, a near-exclusive focus on sex workers ignores the fact that any part of the population is at risk, hence it”creates a false sense of security (among) …. other groups.”

(The names of sex workers cited in the articles have been changed.)

Short notes

Compulsory drug licensing for HIV drugs

A drive to increase awareness of the benefits of compulsory licensing for the national production of drugs in developing countries was launched at meetings in Geneva on March 25-27. The programme is aimed at the wider public health community, focusing particularly on countries worst hit by HIV/AIDS.

Compulsory licensing is the process by which a government grants permission to a local manufacturer to produce a patented item, such as essential drugs, without prior agreement with the patent holder, who however, has to receive adequate remuneration. The meetings which included the World Bank, World Trade Organisation, NGOs, and pharmaceutical manufacturers, were organised by Médecins sans Frontieres (MSF), Health Action International (HAI), and the US-based Consumer Project on Technology (CPT). Bernard Pecoul from MSF said they were deeply concerned at the growing number of lives at risk particularly from HIV/AIDs due to the unequal access to medicines. Bas van der Heide (HAI) explained the issue of compulsory licensing was”too important to leave to patent officers and trade officials”.

Pointing to the”vast disparity in world income and access to essential medicines”, James Love (CPT) said that revised global trade agreements setting new international norms for the protection of intellectual property must address the problems of access to essential drugs for the poor.

Compulsory drug licensing for countries hit by HIV is mooted, Lancet, April 3, 1999