The Prostitutes' Union

By Madhusree Mukerjee

From the Scientific American

Among the poor and most vulnerable, Smarajit Jana has found
a way to slash the incidence of HIV--by organizing sex
workers as any other labor collective

Blanching at the stench of urine, I stumble up pitch-black,
uneven steps to the top floor, which seems to be a rooftop
on which someone has constructed shacks out of brick,
asbestos and plastic. A shaft of light from a street lamp
falls past tenuous bamboo railings onto a figure in a
glittering white sari. She crouches on the bare brick floor
by the roof's edge, holding a mirror in one hand and a
lipstick in another, using the light to make up. Older
residents of the brothel, who expect no clients, crowd into
a tiny room to tell me their stories. “I've spent my life in
this hell,” says Pushpa Adhikari, an ancient woman with sad
eyes who was sold into sexual slavery at the age of nine.
The others demur: thugs used to terrorize the brothels with
nightly rapes and murders, but now that the prostitutes are
united the hoodlums keep their distance. “It used to be
hell--now it's heaven,” corrects one woman, and even
Adhikari nods.

Freeing the brothels from terror is merely a side effect of
the Sonagachi project, an HIV intervention program named
after the red-light district of Kolkata (formerly Calcutta)
where it began. Rural poverty forces millions of Indian men
to migrate to urban centers in search of a livelihood; there
they visit brothels, pick up the AIDS virus and take it back
to their wives. Truck drivers also infect prostitutes along
the major highways. India already harbors at least five
million cases of HIV--the most in the world after South
Africa--but it is too poor, and its health infrastructure
too weak, to permit reliance on drugs. Only if prostitutes
cease to acquire and transmit the virus can the epidemic be
contained, and Smarajit Jana, a public health scientist, has
found a way to accomplish that.

“I strongly believe that for a program to succeed, the
subjects have to adopt its goals as their own,” he explains.
They have: the sex workers run the HIV program themselves.
Jana persuaded them to form a growing collective that now
includes 60,000 members pledged to condom use. It offers
bank loans, schooling for children, literacy training for
adults, reproductive health care and cheap condoms--and has
virtually eliminated trafficking of women in the locale.
Best of all, the project has kept the HIV prevalence rate
among prostitutes in Sonagachi down to 5 percent, whereas in
the brothels of Mumbai (Bombay) it is around 60. Other
sexually transmitted diseases are down to 1 percent. Jana
now works with CARE in Delhi, assisting other social workers
in similarly transferring their HIV prevention programs to
the people they serve. Such community-led interventions have
become integral to the Bill and Melinda Gates Foundation in
its five-year, $200-million effort to combat AIDS in India.


An unassuming man with flyaway hair and a ready smile, Jana,
who is now 53, went through medical school in Kolkata in the
1970s. There he organized students to collect leftover
medicines and visit slums to treat the inhabitants. Medical
school in India is highly subsidized, so “we felt very
strongly that we were morally responsible” to give something
back, Jana recalls. They campaigned and litigated against
hazardous medical products, getting two dozen of them
recalled. When, instead of aiming for a lucrative private
practice, Jana specialized in public health and went off to
run a rural clinic, his parents were horrified.

At the clinic, Jana observed that if a woman had undergone a
tubectomy, for which she had received money from a
population-control program, she invariably blamed any
subsequent health problems on it. Circumstances having
forced her into the operation, she resented it and
influenced others against it. “In the short term, you can
get results with such coercive methods,” Jana realized, “but
in the long term, the program will fail”--as, indeed, the
sterilization effort did. To truly succeed, one needed not
only informed consent but heartfelt consent, which meant
that one first had to understand what made someone tick.

Jana would apply this insight in 1991, when an official from
the World Health Organization asked him to survey the
brothels of Sonagachi for HIV. By then, Jana had found his
niche in occupational medicine, establishing precedents for
compensating factory workers and protecting tea-garden
laborers from pesticides. Jana agreed to the WHO request
only after the official used the phrase “sex worker”: the
concept intrigued him. He opened a clinic in the area, and
when patients finally trickled in, he treated and listened.


The prostitutes' lives turned out to revolve around their
children, which suggested how to make HIV relevant. Jana in
turn explained to the women that he saw them simply as
workers earning a living: “I sell services, so do you.” To
the prostitutes, who despised themselves no less than
everyone else did, the idea was mind-boggling. “Many others
came to ask if I had indeed said this. It had a ripple
effect,” Jana remembers. Gaining a measure of self-respect
became the first step in a long process of empowerment.

Following the survey, Jana undertook to ensure that the
women protected themselves against HIV. He trained a few sex
workers to go around the brothels talking about the virus
and distributing condoms, and he sent researchers along to
take notes on everything. It transpired that if a prostitute
insisted on condom use, her customer just went to someone
else. Unlike AIDS, starvation posed an immediate threat, and
the program seemed doomed. “Counseling, educating--it just
doesn't work,” Jana states. “Higher up in the social
hierarchy, people are able to act on the information given
to them. Not so in the lower levels.”

Thinking of HIV as an occupational hazard gave him the
solution: a workers' collective. “The outcome of a
negotiation depends on the relative power between the two
parties,” Jana explains. “When an individual sex worker
deals with a client, she is weak. To change the power
equation, she needs the support of other sex workers.”

That was not enough, however: Jana also had to loosen
several layers of coercion that perpetuated unsafe sex. He
persuaded the brothel madams that keeping HIV down was in
their interest. To reduce the depredations of gangsters, he
invited their bosses--often local politicians--to tour the
area and converted them to the cause. He lobbied the police
to stop raiding brothels, because if a prostitute lost a
day's earnings she was less likely to insist on condom use.
He argued with syndicate leaders who controlled the pimps
and who ultimately conceded to his economic logic. And
finally, because society's revulsion left the sex workers
feeling worthless and therefore less able to protect
themselves, Jana pitted them against Kolkata's intellectuals
in impassioned, face-to-face debates about morality. As the
women grew in confidence, he removed himself from the scene:
Jana's greatest achievement is his planned obsolescence.

Jana has added community empowerment to the known spectrum
of structural interventions--that is, programs that seek to
alter the forces that maintain harmful behavior, explains
public health scientist Michael Merson of Yale University.
The United Nations's AIDS effort holds the Sonagachi project
up as a “best practice” model. Still, how well it can be
reproduced remains to be seen. Meanwhile the collective has
hosted three conferences, attended by sex workers from
around the world (including the U.S.) who hope to learn its
secret. And while I interview Jana during one of his visits
to Kolkata, hundreds of women wait patiently outside, each
for her turn to meet him. In their eyes, this man who
reached down to help them up wears the halo of a modern-day
savior.