Action for health in the Sonagachi red-light area of Kolkata
The sex workers of the Sonagachi red-light area of Kolkata were a vulnerable and exploited group at the bottom rung of the societal ladder: they had no rights, little education, few opportunities and lived a life full of violence and with the very real risk of ill health. As well as the risk of ill health to themselves, there were also wider public health concerns – most notably of sexually transmitted diseases (STD) and HIV transmission. In this essay we shall look at how the sex workers were able to achieve a previously unheralded change and improvement in their lives and working conditions; achieve their human rights and social justice for them and their community; improve the public health of the area and make changes that are having an effect on the global scale.
So what do we mean by human rights? The Universal Declaration of Human Rights as defined by the United Nations is a list of 30 articles outlining what human rights consist of, and that it is a common standard applicable to all people, everywhere. Article 3 in the declaration states “Everyone has the right to life, liberty and security of person” (Malik et al.). Yet we know the reality is different: for example slavery and trafficking still sadly exist – and did within this group of workers. We know also that access to health care is grossly unequal across different cultures and classes (Braveman et al., London), with those often in the greatest need: the poor and vulnerable being those that are least likely to have access to health care, since the cost both in time and/or money can make it unfeasible to utilize these resources (Gostin).
The approach to achieving empowerment and social justice in Sonagachi was a multi-pronged approach. The initial plan, to improve public health, i.e. through reduced STD rates and HIV transmission by demanding that the sex-workers used condoms and the use of outreach clinics was flawed. Firstly the sex workers were in no position to make any such demands about condom use. Secondly, for the workers this approach was not targeting what they considered to be their main problems: that of the welfare of their children, the lack of banking services, the risk of violence and the lack of basic rights. These were of far greater concern to them than the risk of contracting HIV/AIDS. By re-focusing on what the workers needed and endevouring to mitigate the disadvantages that they faced the project was able to take steps towards achieving social justice. The new focus included the original focus on the health of the workers, but now extended to include concerns about their families, their safety and security. One of the key changes was changing the way in which sex workers were viewed: not as morally corrupt, worthless prostitutes, but instead as professional sex workers and therefore entitled to fair working conditions, such as access to condoms and fair pay. “HIV and STDs [should be viewed] as occupational health hazards” (Basu et al) and treated as such. The aim was to ensure that all lives were viewed as having equal value, and thereby help achieve social justice for the workers (Gostin). Equity and empowerment go hand and in hand (Braveman et al.).
It is an important point to note that the success of the project and the subsequent improvement in public health began to occur when the correct problems were identified. Too often professional researchers, who are quite possibly both physically and ideologically separated from the people that they are trying to help, will identify problems but fail to realise that their problem list may be very different from the problem list of the people being affected on the ground. It is vital therefore to involve the beneficiaries of any public health improvement plan from the outset (Rifkin). The initial approach in Sonagachi could be considered a paternalistic approach, with the public health professionals “knowing best” because they have a wealth of experience and information about improving public health. However in reality, the solution must be a local, homegrown solution, since the community knows intimately what their problems are, what is sustainable, realistic and importantly, in a resource limited setting: affordable. By involving the people being targeted in the project there will likely be far greater buy-in from the community, as they have ownership of their problems (Rifkin). With the development of the peer educators (PE) scheme community participation developed further. Not only did the PE get involved with the community, but they were able to change it and mould it; they had become empowered. The previous paternalistic approach of imposing a particular set of standards and ideals to improve public health (Faden et al), despite being unpopular or difficult to achieve (e.g. increasing condom use to reduce HIV/STD rates) had given way to its opposite: a much more autonomous public health scheme focusing on what really mattered to the sex workers. That the end result was a significant increase in condom use and corresponding decrease in STD/HIV infection rates is a positive – but it was achieved in a way that was acceptable and realistic for the sex workers. It was probably further helpful that being a PE attracted a degree of status, with a small stipend salary and regular working hours: these workers were becoming respected, professional working women, who were able to give advice and support and act as advocates for their fellow work colleagues.
With the development of the PE the sex workers involved in the community began to network with each other, and by talking to each other improved their understanding of health-related matters. Importantly the workers realised that they could individually make a change, and through these small changes they could make bigger changes and affect an entire community or even communities. They also realised that through their networking they could reach other people and professions outside of their immediate environment and make them aware of their issues and consequently create a much deeper understanding of what public health, human rights and empowerment meant to them.
As the grass roots level empowered themselves through the PE scheme, change was also being effected at higher levels. If any societal change is to occur it is not enough to make the change on one level: it must go right up to the highest echelons of society, from local through to national, and must involve all spheres: media, political, law and economics. In Sonagachi the workers were making good use of their ‘capital’ of social networks to access the different spheres and higher level engagement with people would could make policy change. In another example the Treatment Access Campaign in South Africa, an advocacy group raised “public awareness and understanding about issues surrounding the availability, affordability and use of HIV treatments” “Civil society campaigns for health work most effectively when emphasising the indivisibility of civil and political, and socio-economic rights” (London). Change was achieved on a national scale in South Africa and in Sonagachi similar things have been achieved through similar methods.
“A commitment to social justice lies at the heart of public health.” (Gostin). Human rights and societal justice are for everyone – and it is one of the central tenants of the United Nations declaration of human rights. The Sonagachi project showed that by providing the correct environment by allowing the people on the ground to take ownership of their own destinies, identify their own problems and solutions, support them with good training and support national change for the betterment of social justice can be achieved by even the most vulnerable members of society. The sex workers of Sonagachi utilised their existing strengths of strong networking skills to reach out to other communities, and informed higher levels of government and policy makers about their needs and rights. Public health and human rights became one in the securing the safety, stability and development of a community. The original aim of the project to reduce STD/HIV infection rates amongst the sex workers was ultimately achieved – and so could be reasonably judged as having successfully ‘improved’ public health. This is proof that a joined up project, that includes looking after the welfare and schooling of the children of the sex workers, providing reliable and fair banking services, safe home environments and so on – in deed many of the things that people in privileged, ‘developed’ countries take for granted, can effect change across many different areas and act as a method for achieving empowerment and social justice, as well as improving public health.
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