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

Between the President’s Emergency Plan for AIDS Relief (PEPFAR) and Sex Trafficking—Global Public Health as Moral Intervention

Influential as it is, the experimental research program of the Gates Foundation is not alone in defining the agenda of early-twenty-first-century public health. Almost since its inception, the Gates Foundation has evolved alongside and sometimes in close collaboration with a very different kind of global public health intervention, the US-sponsored President’s Emergency Plan for AIDS Relief (PEPFAR), passed by Congress in May 2003 under the terms of the “United States Leadership against HIV/AIDS, Tuberculosis, and Malaria Act (Global AIDS Act).” Hailed as the largest public health program in history to target a single disease, PEPFAR brought an abrupt and unexpected end to almost a decade of neglect by dedicating $15 billion in humanitarian aid over five years to treat the HIV/AIDS epidemic in the developing world. Together with the UN’s Global Fund to Fight AIDS, Tuberculosis, and Malaria, created in 2002, PEPFAR has implemented mass treatment programs making antiretrovirals (ARVs) widely accessible to HIV/AIDS patients in sub-Saharan Africa, South and South-East Asia, and the Caribbean. ³² Between 2003 and 2008, PEPFAR had distributed antiretroviral drugs to some 1.4 million people, funded the testing of some 30 million people, and provided care for a further 6.7 million. The program was reauthorized in 2008, providing a further $48 billion in funding over a period of five years.

Coming as it did after more than a decade of penury with regard to the international AIDS epidemic, the significance of PEPFAR as a turning point in US humanitarian aid policy is indisputable. And yet from its inception, PEPFAR’s mass treatment program was qualified by a series of strict moral conditions that served to delegitimize longstanding public health strategies of harm reduction and practice-based prevention. The “Global AIDS Act” required that at least one third of all prevention funds should be spent on the promotion of sexual abstinence before marriage: PEPFAR prevention programs were to be based on the principles of ABC (Abstain, Be faithful, use Condoms), with condoms being treated as an absolute last-resort. It also singled out prostitution as one of the principle vectors in the spread of HIV/AIDS, and identified the abolition of prostitution itself as one of the end goals of US public health programs. Using the terms prostitution and sex trafficking interchangeably, the act specified that no US-derived funds could be used to promote the legalization or decriminalization of prostitution, that no support would be given to organizations that endorsed prostitution, and that all direct or indirect recipients of USAID funding must take a pledge explicitly stating their opposition to prostitution. The antiprostitution clause had what Melissa Ditmore and Dan Allman refer to as a “chilling” effect on services to sex workers. ³³ According to a report by the Global Network of Sex Worker Projects, some organizations ceased all services to sex workers altogether, some censored or hid their affiliations with sex worker organizations, while others managed to retain US funding by reinventing the terms of their services. ³⁴ Those organizations which were most relentlessly excluded from US funding were sex worker collectives themselves–the very services which had provided the most consistent source of health care and condom distribution to their clients. ³⁵

Many had expected that the moral restrictions of PEPFAR funding would be completely lifted under the Obama administration. Yet while Obama did qualify much of the explicitly theological inspiration behind PEPFAR, he maintained a focus on prevention through abstinence and failed to revoke the antiprostitution clause–perhaps because the new administration remained steadfastly committed to the US’s antitrafficking programs. It was only when a group of NGOs challenged the antiprostitution clause before the Supreme Court in 2011 that it was officially revoked, and even then, the decision only applied to US-based NGOs receiving PEPFAR funding. The antiprostitution clause remained resolutely in place as a fixture of US antitrafficking initiatives. ³⁶ Under Obama then, the PEPFAR antiprostitution clause has been relayed by the US’s antitrafficking protocols, which have come to exert considerable pressure on countries in Sub-Saharan Africa, South and South-East Asia to implement laws that criminalize, detain and provide for the forcible rehabilitation of sex workers.

Taken together, the US’s foreign aid policies have at one and the same time instigated a new politics of repression (focused on the traffic in persons and cross-border circulation of mostly female migrant labor) and intensified preexisting discourses of moral corruption. Writing on Cambodia, Penny Edwards notes that the uncertainties of democratic transition, coinciding with the wholesale adoption of the radical economic reforms of the IMF and World Bank, have generated a discourse of political decline obsessively focused on the transgressions of women. The mass migration of young, impoverished, single women from the countryside to Phnom Penh, to work in the overwhelmingly feminized clothing factories, or in brothels, bars, hotels, and clubs has been countered by systematic acts of sexual violence against women deemed to escape the accepted bounds of familial or marital intimacy. These acts of violence, frequently acid attacks, are carried out by both men and women. The rise of a popular moral vigilantism is at best ignored, at worst openly sanctioned by the government, which during moments of national and religious ritual, becomes increasingly vocal about issues pertaining to women’s dress and behavior. In 2004, notes Edwards:

Prime Minister Prince Hun Sen issued a directive to various ministries, including the Ministry of Culture, the Ministry of Religion and the Ministry of Women’s and Veteran’s Affairs to consider provisions for the improvement of national morality. A focal message of these morality tirades is that women should not only transmit notions of morality, as mothers, but more significantly, it seems, in policing moral boundaries through their own abstention from particular sites, professions and dress. ³⁷

Others have discerned the rise of a similar kind of moral politics in Thailand. Here, the experience of economic liberalization was met with a reactive nationalism on the part of the urban middle class, who anxiously sought to relocate traditional Thai identity in the figure of the rural woman at the very moment young peasant women were moving to the cities to work. ³⁸ Thailand’s National Development Plan of 1992-6—the first to emphasize the importance of the family in maintaining national values—perfectly captured the sense that spectacular economic growth fueled by an influx of foreign investment funds would need to be counteracted by a corresponding rehabilitation of familial order. Even while many sex workers were not from the countryside, and most clients of sex workers were local Thai men, nationalist discourse was firmly focused on the phenomenon of peasant women departing the Thai countryside to service foreign tourists. This discourse only intensified in the wake of the Asian financial crisis of 1997. Rosalind Morris, for example, points to the rapid metonymic slide from financial contagion to prostitution following the devaluation of the Thai baht in 1997. Almost without pause, she notes, political discourse on the Asian financial crisis moved from the failure of the domestic economy to maintain its sovereign boundaries in the face of external threat, to the specter of young rural Thai women prostituting the nation to the foreign sex tourist. “The attribution of commodity desire to the local woman,” she writes, “renders her as one who has departed from home, from authentic Thainess (khwaam pen thai), even before she moves to the city. Few narratives have been more powerful in the literature of the last thirty years than that which laments the loss of authentic Thainess, and it is this loss that the stories of prostitution invariably metaphorize.” ³⁹ It is in such contexts that the idea of the prostitute as a vector of disease, undermining the intimate, domestic space of the family, becomes particularly acute.

The rise of a postcolonial politics of moral regeneration predates the specific interventions of US public health and antitrafficking laws. In Cambodia, for example, the government attempted to pass its own legislation outlawing sex work as early as 2002, and has undertaken numerous crackdowns on brothels,. It is indisputable, however, that US foreign aid politics have reinforced and institutionalized the domestic politics of moral reform through the imposition of specific funding conditions. This has become increasingly clear in recent years, as the US’s anti-trafficking initiatives have taken over where PEPFAR left off. Despite disclaimers to the contrary, US-sponsored antitrafficking interventions in South-East Asia have overwhelmingly focused on migrant (rural to urban or transnational) sex workers. ⁴⁰ It is under the influence of the US antitrafficking initiative that Cambodia revived and promulgated the failed antiprostitution law of 2002, this time under the guise of the Suppression of Human Trafficking and Human Exploitation law. ⁴¹ Predictably, the law left sex workers open to continuous police harassment, including arrest, criminal charges, and forcible rehabilitation. Thailand, which passed a similar law in 2008, even while forced and child prostitution had been on the decline since the 1990s, has used its antitrafficking initiative to detain and deport migrant sex workers from surrounding countries such as Laos, Burma, Cambodia, and China. ⁴²

Together, US global public health policy and antitrafficking programs have converged to conflate female migration itself with sex trafficking; sex work with forced labor; and, by extension, all feminized (female or transgender) mobility outside the family or nation with the spread of disease. This confluence of public health and labor disciplines has had the practical effect of criminalizing sex workers themselves, while simultaneously undermining the fragile infrastructures of care that have been most effective in reducing HIV infection. As a punitive public health intervention that seeks to marginalize or discipline the extra-familial transaction of sex and the nonreproductive performance of female labor, the President’s Emergency Plan has only served to exacerbate the exposure of sex workers to the multiple risks of police abuse, sexual violence on the part of clients, and HIV infection. Yet it is this very exposure that new biomedical prevention strategies are supposed to protect against and this exposure which makes sex workers, among other “at risk” populations, indispensable research subjects in mass prevention trials. What makes the Tenofovir case—and the intervention of the Cambodian sex workers’ union—so remarkable is the fact that it managed to bring together all of these elements in what is surely both a novel form of labor politics and a compelling instance of radical public health activism.

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32. See Vinh-Kim Nguyen, “Government-by-exception: Enrolment and experimentality in mass HIV treatment programmes in Africa,” Social Theory and Health 7 (2009): 196–217;, for an extensive discussion of the forms of therapeutic intervention involved in these mass AIDS treatment programs.[↑]
33. Melissa Ditmore and Dan Allman, “Implications of PEPFAR’s Anti-Prostitution Pledge for HIV Prevention Among Organizations Working with Sex Workers,” AIDS 15.1 (2010): 63-64.[↑]
34. NSWP Global Network of Sex Worker Projects, “PEPFAR and Sex Work: Briefing Paper #1,” (Edinburgh: NSWP Global Network of Sex Worker Projects, 2011).[↑]
35. Center for Health and Gender Equity, Implications of U.S. Policy Restrictions for HIV Programs Aimed at Commercial Sex Workers, (Washington DC: Center for Health and Gender Equity, 2008).[↑]
36. Zimmerman, 2012: 174-175. Zimmerman notes that “one of the chief carryovers from the Bush administration’s anti-trafficking stance to that of the Obama administration is the misconception that prostitution (and sex work more generally) and human trafficking are the same issue. Four years into the Obama administration, the United States’ anti-trafficking policies continue to perpetuate a conflation of sex work and human trafficking” (173-174).[↑]
37. Penny Edwards “The Moral Geology of the Present: Structuring Morality, Menace and Merit,” People of Virtue: Reconfiguring Religion, Power and Moral Order in Cambodia, eds. Alexandra Kent and David Chandler (Copenhagen: Nordic Institute of Asian Studies, 2008): 229.[↑]
38. Jeffrey, 2002: 96-142.[↑]
39. Rosalind C. Morris, “Failures of Domestication: Speculations on Globality, Economy, and the Sex of Excess in Thailand,” Differences: A Journal of Feminist Cultural Studies 13.1 (2002): 52.[↑]
40. Michele Ford, Lenore Lyons, and Willem van Schendel, “Labour Migration and Human Trafficking: An Introduction,” Labour Migration and Human Trafficking in Southeast Asia: Critical Perspectives, eds. Michele Ford, Lenore Lyons, and Willem van Schendel. (London: Routledge, 2012).[↑]
41. Larissa Sandy, “International Politics, Anti-Trafficking Measures and Sex Work in Cambodia,” Labour Migration and Human Trafficking in Southeast Asia: Critical Perspectives, eds. Michele Ford, Lenore Lyons, and Willem van Schendel (London: Routledge, 2012): 41-56.[↑]
42. Empower Foundation, Hit and Run: Sex Workers’ Research on Anti-Trafficking in Thailand, (Bangkok: Empower Foundation, 2012).[↑]