Commercial Sex Work and STD: The Need For Policy Interventions to Change Societal Patterns

From the Editor In the past year, Jonathan Mann had been emphasizing the importance of human rights and human dignity issues in relation to communicable disease control. He was excited by the opportunity to expand this concept into the area of sexually transmitted diseases. The editorial below is the first concrete demonstration of that. It is unfortunate that this voice was silenced by the recent Swiss Air accident. Julius Schachter, PhD Editor THE ARTICLE BY Michele Spina and colleagues in the current issue of STD1 highlights several repeatedly observed trends. First, sex work is often but not always associated with high risk for STD and HIV infection.2,3 Second, where rates of STD and HIV among sex workers and other socalled “core groups” are high, spread of STD and HIV into the larger community may be rapid.4 Third, although in some geographic areas sex workers have high rates of STD and HIV, in other areas rates of these infections among sex workers are remarkably low.1 Fourth, globalization, a trend characterizing many social, economic, and behavioral patterns, includes sex work.5 Often, globalization of industrial/manufacturing functions is accompanied by the globalization of sex work. Of 802 sex workers studied by Spina and colleagues, 176 were foreign born. Many other reports describing the important role played by “foreign” or “immigrant” sex workers are readily available.6 Social, economic, and political disruption often involve simultaneous, sudden increases in numbers of sex workers and migration of populations that tend to be gender specific, leading to increased demand for sex work and increases in “immigrant” or foreign sex workers. Geographic movement of sex workers across Asia and Africa and more recent movement of sex workers from the former Soviet Union and Eastern European countries to countries in Europe and the middle East is well established. Often, migrant sex workers come from countries with higher STD/HIV prevalence than the countries of destination. The extent to which initiation of women and children into sex work involves individual choice may vary, but available data indicate that most women enter sex work as a result of poverty and consequences of rape, infertility, and/or divorce. Larger social patterns that contribute to initiation of sex work may also contribute to movements of sex workers. For example, in Cambodia and India families may sell their female children or young girls in rural areas may be taken from their families in exchange for money, with the promise of employment as nannies or houseworkers in the city; these young girls end up in brothels as sex workers. Another pattern apparently involves promises of employment in other countries in exchange for large sums of money. Once the young women arrive in the country of destination they find themselves without immigration documents; in this vulnerable situation, sex work may be the only option offered them to pay off their debt. Such trafficking in women is observed in many areas globally. In light of these larger societal patterns, it is noteworthy that the public health response to sex work involves, predominantly, interventions to increase safer sex and early STD diagnosis and treatment. An alternative, prevention-focused approach would include analyses of societal patterns and social structural interventions aimed at changing these patterns and the policies that reinforce them. The current public health paradigm assumes a major role for individual choice and individual responsibility despite the reality of societal determination and limitation of individual choices. Although the current public health paradigm is consistent with individualistic ideology and the basic model of clinical medicine, it appears severely limited in its effectiveness, particularly in some situations. The spread of HIV and STD through commercial sex work is a clear example of this limited effectiveness.6 Recent developments, particularly in international health and in work focusing on disparities in health, increasingly recognize the need for a paradigm shift in public health to incorporate recognition of the societal impact on individual choice. The basic question is: which public health intervention would have the greatest impact: those focusing on individual sex workers' practices or those focusing on prevention and control of trafficking in women? For a long time, the implicit social contract in the area of health has been posed in terms of individuals' rights and public health requirements. Perhaps this is the time to reformulate that social contract to include also the “duties of public health” and the “rights of the community and the population”. Personal health is increasingly conceptualized as involving “patients' bill of rights”. Perhaps parallel conceptualization for public health should involve “community's health bill of rights”. For communicable infectious diseases such as STDs and HIV infection, a new conceptualization could emphasize identification and reduction of societal patterns that create reservoirs of infection. Thus in addition to identifying individual level risk factors and risk behaviors and developing interventions to decrease and hopefully eliminate these, public health workers could identify policy interventions to empower communities and individuals to cope with and protect their health despite existing policies with negative health impact. The Joint and Co-Sponsored United Nations Program on AIDS (UNAIDS) has recognized the importance of working directly on the underlying societal conditions that lead to vulnerability to HIV infection.7 The question is no longer “should public health address directly the societal determinants of health?” but rather, “how should this work be approached?” To move forward, a conceptual framework must be identified that can define the relevant societal issues in useful and meaningful terms. To a large extent, the lack of a coherent societal analysis has handicapped the public health capacity to respond to the societal determinants of health status, including HIV/AIDS and STDs.8 It is nevertheless evident that the biomedical framework and vocabulary is not suited to this broader, societal task. In the context of AIDS, modern human rights have been proposed as a framework for identifying and responding to the societal conditions that create and sustain vulnerability to HIV.9 In part, this linkage between health and human rights has been proposed because the modern human rights framework explicitly seeks to identify the societal-level preconditions for human well-being. How these two domains-health and human rights-can work together is well illustrated in the field of women's reproductive health. Prior to the UN Conference on Population and Development in Cairo (1994), population programs focused on providing women with information and education about contraception, along with a range of safe and effective contraceptive service options. However, this rather traditional approach was manifestly insufficient. In Cairo, the goal of population programs was redefined as ensuring that women can make and effectuate free and informed decisions about their reproduction. Recognizing that important societal obstacles impede this capacity, the UN Conference chose to describe these barriers in the language of human rights. Thus, population programs are now called upon to help ensure that women's human rights, including equal rights in marriage and divorce and rights to association and to political participation, are advanced. For only as women's human rights are realized can the full benefits of information about contraception and related clinical services make their full potential contribution. In short, modern population policies and programs that do not also address women's human rights must be considered manifestly inadequate. Thus, a two-pronged approach may be proposed for HIV/STD prevention and control. In addition to the entire range of traditional, highly useful programmatic approaches, public health programs should identify the human rights violations that create or enhance vulnerability to HIV/STD in a particular population. In turn, this leads to working with community and other groups seeking to promote respect for human rights.10 A two-pronged approach allows full consideration of both the individual factors and the societal forces that together determine the course of the HIV/STD epidemic in the community. This will require creativity and courage. Yet the alternative-ignoring the dominant role of societal factors in the spread of HIV/STDs-is both inadequate and unacceptable.