Those images from J.J. Hospital haunted the rest of my journey. I realized that each and every HIV-positive person I was meeting would inevitably suffer that kind of horror before the virus killed her or him off.
But no less harrowing than the physical suffering were the abuses spawned in reaction to AIDS. Mann memorably described those human rights abuses as the AIDS epidemic’s “third wave,” the first wave being the invisible epidemic of asymptomatic infection with HIV and the second the epidemic of illnesses that emerged some years later. I had learned that the third wave of abuses happened in almost every country, whether rich industrialized democracies such as the United States, Communist states such as Cuba or the constituent parts of the former Soviet Union, or impoverished developing countries. But from what I saw that summer in India, I began to feel that the abuses were spreading even faster than the virus itself, rather than as a subsequent wave, fueled by misinformed panic and the opprobrium attached to the disease.
Across India, men and women whose HIV status became publicly known—typically leaked by doctors and other medical staff—were being thrown out of their homes by their families. They were fired from jobs. Families were forced to flee their villages after being ostracized, barred from using roads or wells, their children forbidden from attending school, their homes torched. Newspapers reported uncritically on how patients found to have HIV had been ejected from hospitals, very often left to die uncared for on the streets. People from groups considered at high risk, such as drug users and prostitutes, were being forcibly tested for HIV by medical authorities and the police, often at the behest of the courts. A draconian AIDS control law, introduced in Parliament by the government two years earlier but still to be passed, would institute forced HIV testing, coercive tracing of past sexual partners, and even indefinite isolation of those found to be HIV-positive.
No group in India had been as badly hit by those human rights violations as women sex workers—that phrase had still not replaced the slur of “prostitute.” From the outset, they had been associated with AIDS—because the first domestic cases had been discovered among Selvi and the other sex workers in the Madras reformatory—much as the United States’ epidemic had been indelibly associated with gay men. The association had only intensified over the years.
Thus, in an article that very summer of 1991, The Economist asked, “Since sex is universal, why is AIDS primarily a disease of the poor countries?” The reasons, said the magazine, were that “prostitution and promiscuity are more common, and the traditional sexual diseases are less likely to be treated.”
The most vital part of what needed to be done in developing countries, said The Economist, was to check the spread of HIV from prostitutes to their clients, a view widely espoused by public health experts. “Prostitutes in poor countries are often infected,” the magazine wrote. “They and their clients played a significant role in the spread of AIDS in Africa . . . [and] prostitution seems to be at the heart of the disease’s spread in Thailand, a country whose troubles are less well known but may prove cataclysmic.” Those dynamics were expected to be no different in India and elsewhere in Asia.
And so the AIDS pandemic forced women sex workers everywhere squarely into the public eye and onto the agendas of health ministries. (Almost nowhere were transgender or male prostitutes mentioned; policy makers liked to pretend away any knowledge of such unspeakable persons in their nations.) The attention would have been a blessing had it led to actually protecting prostitutes against AIDS. They desperately needed help—and for too many it was too late already.
Extrapolations from studies suggested that 40 to 60 percent of prostitutes in several sub-Saharan African cities, and 10 to 30 percent of prostitutes in such major Asian cities as Bangkok and Bombay, were already infected. Prostitutes were being wiped out at a pace that dwarfed even the devastation among Western gay men.
To stem the epidemic among prostitutes and their clients, clients would have to use condoms unfailingly, protecting both the prostitutes and other clients from infection. That was an achievable goal in places where prostitutes were able to demand that their clients use condoms. In fact, at the onset of the AIDS epidemic, prostitutes in Western industrialized nations began to insist that clients use condoms or forgo having sex, and their clients usually agreed; as they were aware of the risks. Western prostitutes who contracted HIV did so overwhelmingly from injecting drugs, common among low-income prostitutes and their partners, not through sexual transmission, proving that prostitutes did not inevitably contract HIV as a consequence of their work.
To get clients of prostitutes in developing countries to use condoms was another matter altogether. In such nations, men were unused to condoms even as a means of birth control and disliked using them because they were perceived to reduce sexual pleasure. Condoms were in short supply anyway—few developing countries even manufactured condoms—and were a luxury for the average man, equal in price to that of a meal.
And many prostitutes, particularly in impoverished sub-Saharan Africa and South Asia, were illiterate or barely educated, criminalized by law in almost every country, vulnerable to all kinds of abuse, and so outcast that they rarely if ever had supportive advice or care from skilled medical personnel or social workers. So it was little wonder that it was difficult for them to grasp the threat posed by AIDS until years later, when they saw large numbers of other women falling sick and dying. Even the few women who were aware of the disease and convinced that condoms could prevent HIV transmission typically had little power to overcome their customers’ opposition to using condoms. If a prostitute refused to have sex without a condom, the client would go elsewhere and the woman would lose her livelihood. Consequently, every factor conspired to push prostitutes in developing countries into dismissing the threat of AIDS.
Yet, in a parallel to the pattern in the West, HIV rates remained low among better-off prostitutes, such as those working in nightclubs or hotels or from their own homes, because they had more control over their working conditions, including condom use. Every study showed that the poorer the prostitutes, the higher the rate of HIV infection. Among the poorest groups of prostitutes in Kenya as well as India and Thailand, some studies estimated that an astronomical 80 percent were infected by 1991 or so. Poorer women had to sell more sex to survive, and their poverty meant that they had little power in any aspect of their lives.
But if there was little that the women could realistically achieve themselves, governments certainly could not plead ignorance. WHO, under Mann’s leadership of the Global Programme on AIDS, had provided detailed guidance on that issue.
WHO was initially ill-prepared for the task, as its past efforts to tackle the classic sexually transmitted diseases had focused on massive national identification and treatment programs. That blanket approach meant that the organization had not designed programs specifically for prostitutes and hence knew little about the health needs of women, men, and transgender prostitutes as well as the complex web of difficulties they faced. So Mann, in his iconoclastic but effective manner, had hired a feminist activist, Priscilla Alexander, a key figure in the nascent prostitutes’ rights movement in the United States and Canada.
Alexander was a founding member of COYOTE, a pioneering prostitutes’ rights organization established in San Francisco in 1973—the acronym stands, memorably, for “Call Off Your Old Tired Ethics”—as well as of the North American Task Force on Prostitution, a loose coalition of organizations working for the repeal of the punitive prostitution laws in the United States and Canada, launched in 1979. From the early years of the AIDS epidemic, Alexander had worked on HIV prevention projects for prostitutes. In addition to spearheading studies that improved understanding of the epidemiology of AIDS among prostitutes and other women, in 1987 she had helped found the California Prostitutes Education Project, the only AIDS prevention project in the United States organized by prostitutes on their own behalf. Her expertise and empathy could ensure that WHO’s advice was made respon
sive to the realities of prostitution.
On Alexander’s joining the Global Programme in early 1989, she and Mann convened an unorthodox meeting on AIDS and prostitution. The participants included not just the usual public health officials but also the tiny handful of prostitutes’ rights advocates—including current and former prostitutes—from both industrialized and developing countries, ranging from the United States and Switzerland to India, Nigeria, and Thailand, where a handful of projects (run mostly by local nongovernmental groups) had sprung up to help protect prostitutes from HIV. From the perspective of the prostitutes themselves, it was epochal progress: for the first time ever, they had a seat at policy-making tables and a say in global discussions concerning themselves.
The guidelines that eventually emerged from that process emphasized that narrow HIV-specific efforts—such as merely educating women about the risks or providing condoms to their clients—would fail because the factors that disempowered prostitutes remained unchanged. Instead, governments were urged to view prostitution, when done by consenting adults—whether women, men, or transgender—as legitimate work and in that context take steps to improve their overall working conditions. That could be done by establishing occupational safety standards, providing medical insurance and broad health-care services, and ensuring them remunerative returns on their labor, all part of the panoply of rights and benefits granted to other workers. United action by prostitutes would be vital to tackling the myriad factors that left them helpless, and the guidelines emphasized the need for conscious efforts to build solidarity.
To confront the stigma associated with the word “prostitute” and emphasize their work as labor, deserving of rights and respect, WHO introduced the new term “sex worker” in the guidelines. That marked the first appearance of this term—coined a decade earlier by Carol Leigh, a Bay Area activist, artist, and prostitute—in global policy documents. That positive term, emphasizing that they, like other workers, worked for money and deserved the rights and respect given to all workers, was soon widely embraced by those in the profession, with translations appearing in countless languages around the world. My vocabulary changed, too.
The importance of those developments cannot be overstated: the health of sex workers was now an explicit part of WHO’s responsibilities and policy agenda. And Mann had committed WHO, and through it arguably the entire UN system, to an approach focused on promoting their basic human rights as well as their participation.
But Indian officials paid no heed to WHO’s advice on sex work or, for that matter, the broader commitments about respecting human rights vis-à-vis AIDS that their government had made at the World Health Assembly as well as other international venues. That was so even though India arguably had the most to gain by putting into place effective HIV prevention programs for sex workers—the Ministry of Health and Family Welfare had recently estimated that the country had about 1 million women sex workers, far outstripping any other nation. Even Thailand, with its robust sex industry, was thought to have just a fraction of the Indian figure, at 150,000 sex workers.
Instead, like most other governments, India continued to take the opposite course of singling out women sex workers for mandatory HIV testing, imprisoning them if they were found to be infected, and making every effort to suppress sex work itself. Its disregard for WHO’s advice on sex work was not surprising: the government’s overall policy approach on HIV, embodied in the proposed AIDS Prevention Bill, was diametrically opposed to the numerous WHO recommendations it had formally agreed to.
Every year, the number of women in state custody rose. In the Madras reformatory where Selvi and the other five sex workers remained under imprisonment, as they had ever since April 1986, the number of inmates swelled in the summer of 1990. That, oddly enough, was the fallout of mass raids on Bombay’s red-light areas.
Following a sensationalistic newspaper article in January 1990 claiming that two of every three of the city’s sex workers were infected with HIV, the Bombay High Court directed the police to clear the city of HIV-infected sex workers. Subsequent raids over the next months led to the arrest of several thousand women. The court ordered that they be tested for HIV without their consent. Whether adults or minors, HIV-positive or -negative, all of them were held forcibly in Bombay’s reformatories. When criticism from human rights activists about the abysmal, jail-like conditions at those institutions mounted, the state government decided to deport the women to their home states, as well as to Bangladesh and Nepal if they were from these countries.
And so it happened that nearly nine hundred women from Tamil Nadu and other southern states, along with eighty-five of their children, were transported to Madras by a chartered train. The organizers dubbed it the Mukthi Express—mukthi means “liberation”—implying that the women had found freedom from prostitution. It was Orwellian doublespeak. The women had had no freedom at all from the moment the raids began. Instead, they had been subjected to astounding human rights violations, made all the more inexcusable because the abusive actions had taken place at the express direction of a High Court judge.
They were imprisoned without charge for months. They were denied a court hearing. They were denied legal aid. The judge summarily rejected the plea made by several human rights groups that the vast majority of the women who had been arrested were adults and, not having been convicted of any crime, had a right to liberty. (The main Indian law on prostitution, drawing on the 1949 United Nations Convention for the Suppression of the Traffic in Persons and of the Exploitation of the Prostitution of Others, allows for “rescued” women to be held for three years, outrageously denying them the rights of due process and liberty on the specious assumption that they are defenseless and childlike.) The judge accused those groups of allying with the city’s pimps and brothel keepers.
By the time the Mukthi Express reached Madras Central Station, the state government had passed an order to confine the women found to be HIV-positive until “a cure was found for AIDS.” Tests forcibly carried out on the women showed that the vast majority were HIV-positive. Though the few uninfected women were released, the nearly six hundred HIV-positive women were imprisoned in appalling, overcrowded conditions in the state’s reformatories—including the one in Madras where Selvi was imprisoned—as well as in jails and makeshift camps.
Those women would have remained imprisoned indefinitely but for a public interest case filed in November 1989, a few months before the Mukthi Express’s journey. The case, filed by a maverick young journalist named Shyamala Nataraj, challenged the prolonged imprisonment of Selvi and the five other women in the Madras reformatory. Nataraj, formerly a correspondent for the Indian Express, had gone undercover in search of their story and gained entry to the reformatory by pretending to be a social worker.
She was devastated by her first visit. “Women who had tested positive since 1986 were kept in remand,” Nataraj told me. “Each of them had been picked up along the way over those years, and then they were cordoned off. At that time, they were living in this large dilapidated building, which was so run-down that even the windows had caved in.
“All these women were summoned before me. This official from the remand home went out of the main building and shouted, ‘Hey, AIDS, come here!’ Just like that!
“For me to stand in the veranda and watch them approach from the building they were housed in was the most troubling moment of my life.
“They all filed in one by one. About two dozen women, all of them HIV-positive. They all stood against this wall, and the superintendent said, ‘Listen, she has come to help you. She is a social worker. You talk to her.’
“And then this woman called Vijaya came up to me and screamed, ‘Who do you think we are? Are we cattle that you come and look at us, you social workers? You just make money off us!’
“She looked hard at me and said, ‘Look at you! You are carrying a child. I have a one-year-old child outside that I never get to meet.’ And then she spat on my face and screamed
, ‘If another one of you comes along, I will commit suicide!’ and ran out of the room.
“And then, one by one, they all followed Vijaya, sobbing. You can imagine how I felt!
“Selvi was the one who didn’t say a word. She just cried silently. I noticed Selvi because there was so much anguish on her face.”
Nataraj’s subsequent visits to the reformatory and her questioning of the women made her realize that the women were being held against their will, despite the official line that they were staying there voluntarily. “Most women, when they talked to me, they simply said, ‘There is something wrong with our blood.’ And that seemed to be the extent to which they were aware of AIDS. The remand home officials had told them that they would be looked after till they were cured, and the women had been made to sign statements stating that they were willing to stay in the remand home.”
Shyamala Nataraj
Nataraj, now convinced that she had to do whatever it took to ensure they were freed, filed the challenge to their imprisonment. Remarkably, in all those years, no one else had been moved enough to do so. I was struck that this epidemic was pushing people who did not have formal training in human rights law—from a public health expert such as Mann to a journalist such as Nataraj—to embrace its principles. The same thing was happening to me.
In response to the public interest case filed by Nataraj, the Madras High Court appointed an independent commissioner who asked the women if they had voluntarily agreed to remain at the reformatory. The women said they didn’t know what they had signed. It became clear that the government officials had abused the women’s illiteracy and powerlessness to keep them in confinement.
An Indefinite Sentence Page 15
