Double Exposure—Sex Workers, Biomedical Prevention Trials, and the Dual Logic of Global Public Health

Para-Public Health and Labors of Risk Exposure

It is not surprising that investments on the scale of those undertaken by the Gates Foundation have had a profound effect both on the humanitarian infrastructures of the postcolonial state and the NGOs that service them. Under the influence of the Gates Foundation and its allied organizations, a humanitarian NGO such as Doctors without Borders has spun off its own drug development organization, DNDi (the Drugs for Neglected Disease Initiative) which sponsors clinical trials on selected drug candidates, while a longstanding public health NGO such as Family Health International (now FHI) has developed its own clinical research arm, offering its services to global public health initiatives in much the same way that contract research organizations oversee multinational clinical trials on behalf of the pharmaceutical industry.²⁰ In the meantime, the resurgence of global infectious disease research has overseen a massive, but highly selective and conditional reinvestment in the long-abandoned health infrastructures of the postcolonial state. The multisite clinical research programs undertaken by the Gates Foundation and its partners demand the mass mobilization of experimental field sites in what are often extremely impoverished environments. A recent malaria vaccine trial sponsored by the Gates Foundation and coordinated by the Malaria Vaccine Initiative and Malaria Clinical Trial Alliance involved the construction of eleven clinical trial sites across seven sub-Saharan African countries, sites that are routinely better equipped than existing primary health care clinics. As part of its drug development programs, the Gates Foundation may decide to revive a disused clinic in a remote village, an enterprise which requires the construction of new buildings and state-of-the-art lab facilities, the purchase of first-world lab equipment, and the establishment of reliable electricity and satellite connections, all of which have become unthinkable investments on the part of the state.²¹

In many respects, the global clinical research enterprise functions as a substitute for the developmental state, offering a quasi-welfare relation and quasi-labor contract in an environment where such guarantees (although always restricted) have become increasingly scarce. As noted by Morenike Falayan and Dan Allman, large-scale prevention trials “frequently require thousands of research participants, and hundreds of research staff who work as administrators, outreach workers, clinicians, statisticians, engaged members of the community, and trial monitors on a truly corporate scale.” Moreover, “it is likely that the sheer breadth of human labor investment in this enterprise—especially the number of trial participants engaged—will increase as new health and disease prevention trials are sought.”²² Despite the legal fiction of volunteerism, most stakeholders in the clinical research enterprise recognize that clinical trial work operates, de facto, as an informal employment relation. Wenzel Geissler enumerates the multiple ways in which the “benefits” paid to research subjects are monetized, noting that the sum paid for a day’s research participation (set at slightly higher than the minimum wage) may contribute to rent, to food, or be reinvested in trade.²³ In a context where work opportunities are highly unpredictable, informal, or clandestine, participation in a clinical trial may in fact represent the most stable, most regulated form of employment that research subjects have encountered. It may also provide the most sustained form of health care that trial subjects are likely to experience, albeit one that is exchanged for the calculated risks of the prevention trial.

What distinguishes this new labor relation is the fact that labor’s value is here equated with its very susceptibility to risk—that is, its state of exposure. The global humanitarian research enterprise defines its labor force of human research subjects as a function of degrees of risk—“at risk” populations whose susceptibility to certain kinds of infectious disease is in turn shaped by gender, class, and migrant status.

States of Exposure—Feminized Labor, Sex Work, and HIV/AIDS

Many, if not most biomedical prevention trials are carried out in regions of the world that were once part of the geography of tropical medicine—sub-Saharan Africa, South and South-East Asia, and the Caribbean—and which continue to experience high rates of exposure to certain kinds of infectious disease. These regions are by no means destined for the high rates of infectious disease—resurgent, emerging, and newly drug-resistant—that are currently recorded. Mass prevention trials frequently take place in countries that have suffered severe declines in public health and welfare services as a result of the liberalization policies of the 1980s and 1990s. Infectious disease rates are often closely correlated with these events—in Tanzania, for example, one of the many sub-Saharan African countries that hosts mass prevention trials for mosquito-borne disease, drug-resistant malaria rates skyrocketed when the environmental management programs implemented by the developmental state were abandoned under pressure from IMF-induced spending cuts and replaced by pharmaceutical solutions.²⁴

The history of HIV/AIDS is somewhat exceptional in that prevention programs attracted a high rate of international aid investment at a time when public health budgets were otherwise being cut back—prevention programs that, during the nineties at least, were often specifically targeted at “at risk” populations such as sex workers. The spread of the HIV epidemic in Africa, the Caribbean, and South and South-East Asia coincided with the profound economic restructuring of the postcolonial developmental state that was pursued under the auspices of the World Bank and IMF during the 1980s and 1990s. In South-East Asia, trade liberalization and export-oriented industrialization created a demand for low-cost, flexible, non-militant—in a word, feminized—labor, provoking a mass migration of young, unmarried women from the countryside to urban export zones, to work in the textile industries, domestic service, street trade, or sex work. Having undertaken these reforms as early as the late 1970s, Thailand came to serve as a model that other countries throughout South-East Asia would seek to emulate during the following decade. Its development plan of 1977-81 ushered in a series of trade liberalization, tariff, and anti-labor measures which, by the mid-1980s, had transformed the export-oriented textile industry—overwhelmingly staffed by cheap, non-unionized women workers—into the driving force of the economy.²⁵ During the same period, the Thai government followed the advice of World Bank and invested heavily in its tourism infrastructure, a move that led to the inevitable expansion of the entertainment and sex industries. As the government disinvested from rural agriculture, the numbers of young women migrating from the countryside to urban, industrial areas soon outpaced that of men. In a period marked by extreme state repression of any kind of labor activism, working conditions in the feminized industrial and service sector—garment factories, households, and the sex industry—were harsh. High levels of child labor were reported in each of these sectors. Workers who had migrated from the countryside were often indebted to owners and managers for the price of their transport and training. Detention in workplaces (brothels, factories, or households) was common, as were disciplinary measures such as fines for work infractions. Sex work offered much higher levels of pay than other comparable forms of employment for migrant women. However, sex workers were also subject to particularly violent forms of intimidation, both from clients and from sectors of the police, military, and state that were themselves deeply involved in running the sex industry.²⁶ In a context of rising HIV infection, these conditions were disastrous. In Thailand, HIV prevalence among brothel-based sex workers nationwide had reached a median rate of almost 25 percent by the early 1990s.²⁷ In Cambodia during the same period, the prevalence rate among the same population was estimated at over 50 percent, one of the highest rates in South Asia.²⁸

These statistics might have been ignored if they did not also impact one of Thailand’s most successful economic exports—tourism—and threaten to spread into the general population via the clients of sex workers. In the early 1990s, then, the Thai government undertook an aggressive public health campaign, requisitioning and expanding a preexisting network of public STI clinics to promote condom distribution among high-risk groups such as sex workers. Thailand’s relatively early HIV prevention campaigns—among the first and most comprehensive to be undertaken in South Asia—were praised by international health organizations as a model for stemming the infection in the developing world. The 100% Condom Use Program was subsequently emulated by other countries in South-East Asia, and by the mid 1990s seems to have contributed to a sizeable decline in infection rates among sex workers. Yet in its initial stages, the program relied heavily on public health officials and police—themselves responsible for frequent intimidation of and violence against sex workers—and was seen by sex workers as a means to punish and control them as much as a health service.²⁹ Perhaps the most insidious threat to prevention campaigns during this period was the continued criminalization of sex work itself. The preventative health campaigns mandated by Thailand, Cambodia, and other South-East Asian states during the 1990s proceeded alongside sporadic crackdowns on brothel-based sex work, a practice that had the perverse effect of pushing sex workers out of formal establishments into street or home-based trade, where they were inaccessible to public health programs.³⁰ Thus, while prevention programs seem to have led to a significant reduction in HIV prevalence among brothel- and bar-based sex workers, sex workers trading outside of formal establishments have been found to have much higher rates of infection.³¹ In Thailand, rates of infection seem to be particularly high among Hill Tribe people (who are not Thai citizens) and migrant sex workers from neighboring countries such as Burma or China, who are increasingly being targeted under Thailand’s antitrafficking laws.

Even the relative successes of these early practice-based prevention programs, however, have been compromised by US global public health and foreign aid interventions, which mandate criminalization of migrant sex workers (under antitrafficking laws) and withdraw funding from all but the most punitive of prevention services directed toward sex workers.

20. On Doctors without Borders and DNDi, see Redfield, 2012; on Family Health International, see http://www.fhi360.org/en/Services/GRS/index.htm. Accessed 1 Nov. 2012. [↩]
21. Jef Akst, “Powering Clinical Trials,” The Scientist 25.8 (2011): 16-17. [↩]
22. Morenike Oluwatoyin Folayan and Dan Allman, “Clinical Trials as an Industry and an Employer of Labour,” Journal of Cultural Economy 4.1 (2011): 98. [↩]
23. P. Wenzel Geissler, “’Transport to Where?’: Reflections on the Problem of Value and Time a propos an Awkward Practice in Medical Research,” Journal of Cultural Economy 4.1 (2011): 51-52. [↩]
24. Ann H. Kelly, “Will He be There?: Mediating Malaria, Immobilizing Science,” Journal of Cultural Economy 4.1 (2011): 73. [↩]
25. Leslie Ann Jeffrey, Sex and Borders: Gender, National Identity, and Prostitution Policy in Thailand, (Vancouver: UBC Press, 2002): 74-124. [↩]
26. See Kasumi Nishigaya, “Female Garment Factory Workers in Cambodia: Migration, Sex Work, and HIV/AIDS,” Women and Health 35.4 (2002): 27-42; and Annuska Derks, Khmer Women on the Move: Exploring Life and Work in Urban Cambodia, (Honolulu: U of Hawaii P, 2008) for a parallel history of the feminization of labor in Cambodia. With a time difference of approximately ten years, Cambodia’s history of labor restructuring closely follows that of Thailand. In the aftermath of UN-supervised democratic elections in 1993, the Cambodian government undertook a program of economic reform which oversaw the rapid expansion of both the export-oriented garment industries and the urban service sector. By the late 1990s, textile factories had become the largest employer of working-age women and the largest foreign exchange earner for the Cambodian economy. Sex work in brothels, karaoke bars, nightclubs, massage parlors, and in the street had become the second largest employer of women. [↩]
27. Jeffrey, 2002: xiv. [↩]
28. Amanda Dumey, “The Sex Worker’s Dilemma: Keeping Cambodia’s Sex Trafficking Law from Negating the Successes of the 100% Condom Use Program,” Tulsa Journal of Comparative and International Law 16.2 (2009): 220. [↩]
29. Deanna Kerrigan, Andrea Wirtz, Stefan Baral, Michele Decker, Laura Murray, Tonia Poteat, Carel Pretorius, Susan Sherman, Mike Sweat, Iris Semini, N’Della N’Jie, Anderson Stanciole, Jenny Butler, Sutayut Osornprasop, Robert Oelrichs, and Chris Beyrer, The Global HIV Epidemics Among Sex Workers, (Washington DC: World Bank, 2013): 125; Lisa Maher, Julie Mooney-Somers, Pisith Phlong, Marie-Claude Couture, Ellen Stein, Jennifer Evans, Melissa Cockroft, Neth Sansothy, Tooro Nemoto, and Kimberly Page. “Selling Sex in Unsafe Spaces: Sex Work Risk Environments in Phnom Penh, Cambodia,” Harm Reduction Journal 8.30 (2011): 4. [↩]
30. Kerrigan et al., 2013; Jeffrey, 2002: ix; Derks, 2008: 88-118. [↩]
31. Kerrigan et al., 2013: 126-127. [↩]