“Typhoid Mary” and “HIV Jane”: Responsibility, Agency and Disease Prevention

Abstract

The construction of disease risks as knowable, calculable and preventable in dominant social science and public health discourses has fostered a certain kind of logic about individual risk and the responsibility for infection. Disease control measures that have developed out of this logic typically fail to recognise the socio-structural roots of many high-risk behaviours that are linked to the spread of infection. Instead, they hold the disease carrier responsible for managing his/her own risk of infection of others, and rely on constraining the agency of the carrier (e.g. by constraining movement, contact or occupation). In occupations associated with a high risk of infection, the idea of responsibility of the actor implicitly raises issues of “professional responsibility”. Using the case of “Typhoid Mary” and a hypothetical case of “HIV Jane”, this paper explores some of the problems with making sex workers responsible for the prevention of HIV transmission. It argues that for the notion of “responsibility” to make any sense, the HIV-positive person must be in a position to exercise responsibility, and for this they must have agency.

Résumé

Le discours dominant dans les sciences sociales et la santé publique estime qu'on peut connaı̂tre, calculer et prévenir les risques de morbidité, ce qui a encouragé une certaine logique sur le risque individuel et la responsabilité de l'infection. Les mesures de lutte contre la morbidité issues de cette logique méconnaissent les origines socio-structurelles de beaucoup de comportements à haut risque. Au contraire, elles estiment qu'il incombe au «porteur de la maladie» de gérer le risque qu'il a d'infecter autrui, et veulent limiter l'action du porteur (p. ex. en restreignant ses mouvements, ses contacts ou ses occupations). Dans des professions associées à un risque élevé d'infection, l'idée de la responsabilité du porteur soulève implicitement la question de «responsabilité professionnelle». Utilisant le cas historique de «Typhoid Mary» et un cas inventé de «VIH Jane», l'article étudie les problèmes soulevés quand on responsabilise les professionnel(le)s du sexe de la prévention de la transmission du VIH. Il affirme que pour que la notion de «responsabilité» ait un sens, la personne séropositive doit pouvoir exercer sa responsabilité et donc avoir une latitude d'action.

Resumen

En los discursos dominantes de las ciencias sociales y la salud pública se han construido los riesgos de enfermedad como elementos que se pueden conocer, calcular y prevenir, fomentando ası́ una cierta lógica acerca del riesgo y la responsabilidad individual con respecto a la infección. Las medidas de control de las enfermedades que se han desarrollado a partir de esta lógica desconocen las raı́ces socio-estructurales de muchos comportamientos de alto riesgo vinculados a la propagación de infección. Al contrario, dichas medidas consideran al “portador de la enfermedad” el responsable de manejar su propio riesgo de infectar a otros, y pretenden restringir el movimiento, contactos o actividades del portador. Con respecto a las actividades asociadas con riesgo de infección, la idea de la responsabilidad del portador plantea asuntos de “responsabilidad profesional”. Usando el caso histórico de “Marı́a Tifoidea” y el caso hipotético de una tal “Juana VIH”, este artı́culo examina algunos de los problemas inherentes en responsabilizar a las trabajadoras del sexo por la prevención de la transmisión del VIH. Plantea que para que tenga sentido la idea de la “responsabilidad”, la persona viviendo con VIH debe estar en una circunstancia que le permita hacerse responsable.

Key Words:

• health policies and programmes
• infectious diseases
• HIV transmission (sexual)
• safer sex promotion
• agency
• sex workers

The HIV/AIDS epidemic has been characterised as the greatest plague in human history. The magnitude of the epidemic and the negative moral connotations associated with the routes of transmission (e.g. promiscuity, illicit drug use and sex work) add dimensions of complexity to the disease prevention and control strategies.¹²³ In contemporary disease prevention models and policies, the responsibility of disease prevention has been placed heavily upon the hosts and vectors of the disease who make up the groups of individuals associated with the routes of disease transmission (also termed high risk groups).⁴⁵⁶⁷ In such models, individuals are treated as if they are independent of the socio-economic contexts in which they live, and regarded as rational actors in the transmission cycle of the disease. Disease control efforts therefore are heavily focused on educating the actors about the disease and their responsibility to prevent transmission. The assumption is that informed individuals make rational choices that will protect themselves and others. Actual punishment in the form of imprisonment or implied punishment in the form of quarantine is available for those individuals who fail to “choose rationally”.

In the epidemic of HIV/AIDS, sex workers, along with other marginalised groups, have become the new targets for disease intervention. The notion of actor responsibility raises questions of professional responsibility when it is associated with the risks of HIV infection in sex work and the understanding of the risk and its management.

This paper develops and presents a critique of the idea of individual and professional responsibility in the control of HIV, particularly as this relates to sex workers. Following writers such as Sen,⁸⁹ Nussbaum¹⁰ and Giddens,¹¹ we situate the analysis of sex worker responsibility within a broader framework of structure and agency¹²—a term defined broadly as the autonomy or freedom available to an individual, which is “inescapably qualified and constrained by the social, political and economic opportunities that are available”.⁸

For the notion of professional responsibility to make any sense, the sex worker must be in a position to exercise that responsibility, i.e. as an actor she must have the freedom and capacity (or agency) to assume that mantle.

A starting point for thinking about the issues is the seemingly unrelated case of “Typhoid Mary”. Her temporal distance and the fact that the disease involved was quite different permits generalities about the role of agency and occupational responsibility in infection control to be examined. Based on the case of Mary, a modern day (fictional) counterpart of “HIV Jane” is constructed, and the lens of agency developed with Typhoid Mary can be applied to HIV-positive sex workers and their role in HIV prevention

Truck stop, main route to Malawi and Zimbabwe, Moatize, Mozambique, 2002

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The case of Typhoid Mary

Typhoid is a bacterial disease transmitted by ingestion of contaminated water and food—the oral-faecal route—and chronic asymptomatic carriers are a significant reservoir of infection.¹³ In the pre-antibiotic era, the disease had a case–fatality rate of about 12%. In the West, this was reduced to around 1% after the introduction of chloramphenicol in 1948. However, modern outbreaks of typhoid in the developing world continue to carry a case–fatality rate of around 10%.¹³

Mary Mallon—a cook working in New York at the turn of the last century, who became widely and unsympathetically known as “Typhoid Mary”—was one such asymptomatic carrier.¹⁴ In March 1906, Mallon was working for a wealthy banker in New York when members of her employer's household contracted typhoid. Mallon, on testing positive for typhoid bacilli during a sanitation investigation by New York health officials, was detained in an infectious diseases hospital in relative isolation for a period of three years. She was released on condition that she kept in contact with the city's health department and did not work with food. Initially, following her release, she earned a living washing clothes, but finding the income insufficient for her needs, she returned to the food industry under the assumed name of Mrs Brown. She worked as a cook in the Sloan Maternity hospital for three months in 1915, during which time 25 staff contracted typhoid (two of whom died). When she was identified, she was returned to the infectious diseases hospital and spent the next 23 years there, until her death in 1938.¹⁴

Agency and Typhoid Mary

The Mallon case is illustrative of a traditional public health approach to disease prevention and epidemic control that combines methods of education and punishment on the disease vector (real or potential). This approach developed out of the contagion theory of disease (a biological explanation of infection, which itself evolved into the germ theory) and won out over the more environmentally and contextually focused miasma theory.¹⁵ Essentially contagion theory posited that an infective agent that passed from an infected individual (perhaps through a vector, an intermediate host or an environmental reservoir) caused disease to an uninfected individual. This is in sharp contrast to the miasma theory, which posited that disease was caused by environmental exposure to “bad airs”. Under the contagion theory, disease prevention and control is achieved by identifying those individuals who are infected (case identification), identifying those with whom they have been in contact (contact tracing), and testing and/or isolating the case and the contacts to contain further spread of the disease.

As illustrated in the case of Typhoid Mary, in the control of epidemics this process often relies on coercive measures, including limitations on movement, activity and human contact. At its most extreme, the public health measures rely on the incarceration of infectious individuals. However, more often, such restrictions merely require the infected individual to act and behave in such a way as not to endanger others. The public health measures used in many of the affected countries to control SARS are a case in point.¹⁶¹⁷ The responsibility for infection control rests upon the infectious individual, who is obliged to safeguard others against the danger of the self. The responsibility of the Public Health Authority starts with case detection, tracing and testing, and ends (assuming compliance) with educating the rational, infected individuals about the disease and their responsibility. As one health officer from Mallon's time was quoted to say: “Inform them that they are carriers. Most persons so informed will care for themselves in such a way that they will not be a menace to the public.”¹⁸ This, indeed, is the historical expression of an assumption of the modern day information, education and communication strategy—that an informed actor will make rational choices.¹⁹²⁰

Notwithstanding the importance of information and education, this strategy alone is often insufficient. The self-imposed restrictions on the disease carrier often reduce their agency by constraining the variety of activities they can safely engage in. Yet, with the exception of life-long incarceration, the capacity of a person to adhere to limitations on their activity and to assume responsibility for others requires, counter-intuitively, a sufficient degree of agency to live within those restrictions.

Agency however, is not equally distributed amongst the population, whereby every individual can freely choose and act. The broader social, political and economic milieu in which people seek to act, and factors such as education, wealth and tradeable skills—all interact and influence the extent of the agency available to the individual, and their choices and actions.⁸

What the traditional public health assumption fails to consider is the burden its measures impose upon the disease carrier. If the state reduces a person's agency in such a way that it inhibits their capacity to comply, the health control measure itself is bound to fail.

This was, arguably, why following her initial detention, the effort to restrain Mallon from handling food failed. In Mallon's case, the restriction meant a change of occupation from food handling to laundry work. However, as a poor, female, Irish Catholic immigrant to a heavily gendered, ethnocentric and Protestant-controlled city, Mallon's life opportunities were significantly restricted even prior to her contracting typhoid. The coerced occupational change only acted further to restrict the already limited agency that Mallon had. This burden, which the state failed to recognise or take responsibility for, eventually resulted in Mallon failing to comply with the occupational restriction. Mallon saw her choices reduced to: (1) stay in poverty, or (2) return to her former profession. Her return to the kitchen, which resulted in a further outbreak of typhoid and two deaths, triggered the even more extreme and punitive response of incarcerating her for life.¹⁴

The example of Mallon is not peculiar to her day. The modern day equivalent of Mallon's case was a young woman working as a salad maker in the late 1980s at a fast food outlet in the US state of Maryland, who was identified as a typhoid carrier. Once identified by health officials, she was taken immediately to an infectious diseases specialist who told her to go on leave from her job, take the medication and come and see him again. On her return visit she explained that the drive was too long, the medication wasn't doing anything and she was going to take herbs instead. “Besides,” she added, “the bastards fired me.”¹⁸ When asked what she was doing next, this thoroughly modern Mary replied that she was working at another fast food outlet. What is instructive about the case is that her reaction to the loss of income was exactly the same as Mallon's. Conceal the disease; seek work elsewhere. Social responsibility and economic insecurity are not easily reconciled.

The themes of agency, risk and responsibility in the control of typhoid are repeated, although with greater complexity, in the control of HIV. In many parts of the world, the spread of HIV remains associated with (though not exclusively) marginalised social behaviours such as injecting drug use and promiscuous sexual activity (usually attributed to men who have sex with men and sex workers).²¹²²²³ As with Mallon, disease prevention that targets sex workers also raises issues of occupational responsibility and restriction. Consider, for instance, the case of “HIV Jane”—a female sex worker. The example, and the discussion that follows, is about female sex workers, not because males do not engage in sex work but because females make up the majority of sex workers, and it is they who are by far the most affected by the disease prevention programmes and policies regulating sex work.

The case of “HIV Jane”

Jane Doe, aged 24, has been a sex worker for two years. She tested positive for HIV following a recent consultation at a clinic where she was screened for a range of sexually transmitted diseases. Jane returned to sex work the same day she received her test results. She does not inform clients of the test results; however, she does insist on the use of condoms, unless the client pays extra, in which case she is less insistent.

In many respects Mary Mallon and Jane Doe are very different. Their diseases are different—one viral, the other bacterial; the routes of transmission are dissimilar; Mallon's case occurred almost a century ago, while Jane's might well have occurred yesterday. Yet the principles that guide the disease prevention strategies that restricted the livelihood of Mary, and restrict Jane's today, are strikingly similar.

Disease prevention and HIV Jane

Much of the contemporary public health and social science discourses on infectious disease prevention draw on the calculus of risk, developing the idea of risk management and risk reduction (or harm minimisation). In what Castel termed “autonomised management of population”,²⁴ epidemiological expertise and quantitative capability gave rise to the presumption that the risks associated with infection were “knowable, calculable, and thus preventable”.²⁵ The dominant discourses depict a direct relation between individual action and the safety of the population with the cultural sensibilities of epidemiology supporting and reinforcing those of health education. In this scenario, individuals are cast as the rational self-governors of risk. By extension, the level of risk borne by a society is determined by the action of individual citizens, each of whom is privately responsible for the management of her/his own risk.

Despite the change of public health rhetoric since the time of Typhoid Mary, the principle of disease prevention remains largely the same. Under contemporary discourses, most HIV prevention strategies assume, with some variation, that individuals are rational, and that informed individuals make rational choices that will protect themselves and others.²⁶²⁷ The AIDS Risk Reduction Model (ARRM), for instance, which is fairly typical of this approach, focuses on the importance of individual cognitive processes around knowledge, knowledge acquisition and the mental algebra involved in risk–reward calculations.²⁸ The approach is highly individualistic, and relies on a relatively facile account of socio-structural factors that affect behaviour.²⁹ Those who “knowingly” place others at risk are to be blamed for their irresponsibility or judged irrational in their decision-making.²⁵³⁰³¹ Where sex work is concerned, a layer of moral inappropriateness is added by the association between the risk of infection and socially unacceptable behaviour.*

The state can, and often does, demand that people who are positive for a disease take individual responsibility for their infectiousness— and by implication the safety of others. Where individuals do not take their responsibilities seriously, the state has the power to intervene. In the Indian states of Maharashtra and Karnataka, for example, the Human Immune Deficiency Virus (HIV) Prevention Bill (1999) makes it an offence knowingly to transmit the virus to others:

“No person who knows or in all reasonable probability would have known that he has HIV infection shall intentionally or knowingly engage in any practice or behaviour or do or abstain from doing any act, which places or has a tendency to place any other person at risk of HIV infection.” S.4(1)³²

“Every person cognizant of his being infected with HIV shall within such time and in such manner as may be prescribed give information of such infection to the Deputy Director having jurisdiction over the area.” S.8(1)³²

In other instances, the prohibition on conduct by infected persons is covered under the more general criminal or penal codes against causing physical harm. Section 269 of the Indian Penal Code states in part that a person who acts negligently in a way “…likely to spread the infection of any disease dangerous to life” shall be punished with up to six months' imprisonment or a fine, or both, and under S.270 a person who acts malignantly shall be punished with up to two years in prison or a fine, or both.³³

A recent Scottish court decision similarly confirmed the “knowing transmission of HIV” as an offence, when a man was sentenced to five years' imprisonment for “culpably and recklessly transmitting HIV infection”.³⁴ Within the 50 states of the US, numerous legal provisions also exist to control the conduct of HIV-positive people.³⁵

Sex workers, risk and the law

The legal provisions to prevent the transmission of HIV (necessarily) reduce the choices of their target. Thus, when the legal provisions seek to prevent a person from working within their profession and as a result, that person suffers a loss of earnings and potentially their entire livelihood, this is a serious restriction of agency. Not unlike the treatment of Mallon, measures that have specifically been taken with HIV-positive sex workers to prevent them from working in the industry include imprisonment, detention in quarantine facilities, or other legal or quasi-legal action.³⁶ In places where the industry is regulated, many governments have put in place separate legislation to prevent the “Janes” of sex work from infecting “the public”. For instance, under the Australian state of Victoria's Prostitution Control Act (1994) S.20:

“A person must not work as a prostitute during any period in which s/he knows that s/he is infected with a sexually transmitted disease.” ³⁷

In another Australian jurisdiction, New South Wales:

“…public health orders can require a person suspected of placing others at risk of HIV infection to do any one, or more, of the following: refrain from specified conduct e.g. sex work, undergo specified treatment or counselling, submit to supervision, undergo treatment, and be detained…” ³⁸

Similar provisions exist elsewhere in Australia, under which HIV-positive sex workers are not permitted to continue their employment and restrictions can be placed on their movement, including a curfew.³⁸

In so far as the legislation assumes that self-control and discipline are the keys to disease prevention (and knowledge and rationality inform self-control), the worker is given the responsibility of making (or keeping) herself “safe” and “disease-free” for the pleasure of the customers.³⁹ Under this analysis, the occurrence of HIV infection in sex workers may be understood as a failure of their responsibility in self-care, and in turn, the care of their clients. The choice of a worker to continue working once she knows herself to be HIV-positive may be seen as a violation of her professional responsibility. Thus, the HIV-positive sex worker is “deviant” and construed as deliberately putting her customers at risk. This discourse of responsibility, more than anything, reflects the need of the public to create what Sacks describes as a “symbolic boundary between the stigmatised [sex workers] and unstigmatised [client]”.⁴⁰ By placing the responsibility and blame onto the sex workers, the public gains a sense of safety from the “vectors of disease”. Society seeks to protect itself from its deviants, and yet the deviants are just the tail end of the distribution of the whole population—only separable with the creation of symbolic categories.⁴¹ The construction of the dangerous sex worker is uncannily reminiscent of the Frankenstein-like transformation of Mary Mallon into the monster that was Typhoid Mary.¹⁴

Yet being responsible, as is required under legislation governing the transmission of HIV, is not a passive act. Responsibility assumes agency; at the very least a person must have the capacity to act responsibly. Just as New York health officials assumed that Mallon would be able to conduct her life without working as a cook, so governments today assume sex workers have alternative means of financial support. Yet the reasons for women entering and leaving sex work are complex, often beyond their control and frequently economic.⁴²⁴³ Given this, the pivotal question for the success of HIV prevention and control strategies involving sex workers then becomes: do sex workers have agency? More precisely, as required by the traditional public health discourse, do sex workers have the level of agency necessary to carry out their professional responsibility of safeguarding themselves and their customers from the risk of infection? This also begs the question of whether, even if sex workers do have sufficient agency, they and not their clients should be held responsible for their clients' health.⁴⁴⁴⁵

The question around agency and sex work, although not necessarily discussed in that language, has seen two broad positions advanced.⁴⁴ One holds the sex worker to be the coerced victim, the other holds her to be a person making the best choice from the available (and perhaps limited) options.⁴⁵ There is of course no quintessential sex worker situated within one or other position, but varying levels of agency and options.⁴⁶ Consider the following description of some Costa Rican sex workers:

“The lives of these women are marked by violent abuse at the hands of clients, police officers, and partners. In the 10 months that I spent with these women, not one day passed that I did not witness or see the results of a violent attack. One woman, for example, had her arms burned when she was tied to a bed frame. Another had her jaw dislocated four times in 10 months because of the frequency with which she was required, often by force, to perform oral sex. Yet another woman had her right breast cut so badly that her nipple had to be re-attached surgically; and the list goes on.”⁴⁷

This situation marks one extreme along a continuum, from professionals with an enormous capacity to exercise choice (including the choice to engage in sex work itself) to survivors, those whose needs are so immediate and so basic that their agency is severely constrained.⁴³ Where any one sex worker is positioned is often determined by structural factors, including the regulatory environment of where she works, the level of poverty in the environment and personal factors such as abuse during childhood, drug dependency, minority status (e.g. racial, ethnic or migrant), and her level of education and other work skills—all of which affect the conditions in which she finds herself working.^{4345484950515253}

Against the common perception that sex workers are vectors and reservoirs of disease, HIV infection among workers at the upper end of the continuum is no higher than for women who do not engage in sex work.⁵⁴ Unfortunately, the distribution of sex workers on the continuum of agency is heavily skewed. Most sex workers in the affluent Netherlands tend to have relatively limited agency; only a small proportion enjoy the freedoms and choices associated with the higher end of the continuum.⁴³ The violence, for instance, described in the Costa Rican quote is repeated in the literature on the economically most well-off settings through to the most deprived, e.g. in Britain,⁵⁵ Canada,⁵⁶ the Netherlands,⁴³ Sri Lanka⁵⁷ and South Africa.⁴⁸ Only a small proportion of sex workers in these studies experienced levels of agency consistent with work choice and job satisfaction. The experience of the rest echoes themes of poverty, threats of arrest and violence from multiple sources (including police, pimps, clients and partners).

Evidence of the relationship between agency and responsibility in the daily practice of sex workers can be found in many places, the most relevant of which is perhaps the negotiation of condom usage, an area considered essential to HIV prevention. Numerous studies have reported that the power status of an individual affects the negotiation of condom use.⁵⁸ Against the common presumption that sex workers ought to practice safe sex, studies have repeatedly reported that those who are in a position to negotiate safe sex tend actively to comply with safety standards and use condoms as routine tools of the trade.⁵⁹⁶⁰ For instance, in a study conducted during the initial phase of the HIV/AIDS epidemic in London, it was found that in a group of sex workers recruited at a clinic, fear of AIDS had increased their condom use from 54% to 84%. Sex workers also reported a decrease in high-risk sexual services and an increase in low-risk ones. Similar patterns have been reported in other studies conducted in Britain,⁶¹⁶² the US⁶³ and Australia.⁶⁴⁶⁵

Studies have also found that in circumstances where safety precautions had not been taken, financial concerns or the use of force by clients was often responsible. One study of condom use by sex workers in India, for instance, found that the younger workers were less likely to use condoms than the older ones. In an industry where youth was an important currency, the younger ones felt that the use of condoms would inhibit their earning capacity during the peak of their careers.⁶⁶

Perhaps more central to the discussion of agency and responsibility is the fact that in sex work, power largely resides with the client. Research has repeatedly identified the unwillingness of clients to engage in safe sex as an important factor in commercial sexual transactions, e.g. in India,⁶⁷ Britain⁴⁰ and South Africa.⁶⁸⁶⁹ Indeed, many studies show that clients will actually pay more for unsafe sex than for safe sex,⁷⁰ which has to increase the attractiveness of unsafe sex to the economically vulnerable sex worker.⁷¹⁷² Furthermore, unsafe sex is common when clients use physical force to overcome workers' unwillingness to engage in unprotected sex.⁴⁷⁶⁹ As one Johannesburg sex worker said: “Sometimes we used condoms but sometimes they throw them away and try to beat us”.⁶⁹ In certain cultures, sex without condoms is viewed as a testament to a worker's cleanliness (and their HIV seronegative status), and clients will therefore often refuse to engage in sexual transactions with workers who insist on using condoms.⁶³⁶⁷ Consequently, some sex workers have no choice but to put their own health at risk, as well as their clients'. The more dependent the workers are on sex work to provide their income, the less choice they have in safety negotiations. Between immediate physical survival and long-term health risks, the decision is rationally made in favour of immediate survival. The similarities with Mary Mallon are almost palpable. As Thomas expressed it:

“…no sex worker forces a client to have sex, protected or unprotected, whereas threats of, or actual, physical violence, including rape, in order to obtain unprotected sex are a far from rare experience, especially for women working the streets.” ⁷³

In light of the disadvantaged work environment of many sex workers, the risk of contracting HIV must necessarily be weighed as just one of many occupational hazards. For the more disadvantaged sex workers, even in situations where choice applies, the concerns of everyday life, combined with the knowledge of the lengthy asymptomatic period of the disease, allows the risk of HIV infection to assume a relatively low position in the list of life's priorities. The perceived material benefits of sex workers' high-risk behaviours thus outweigh the risks of HIV infection and the risk of getting caught. One sex worker quoted by Varga said: “If you start making health issues a priority and are very strict in terms of safe sex… you become a starving sex worker very quickly.”⁶⁸ Another said, “When you wake up in the morning, they [sic] do not think about how to prevent AIDS and stay healthy. Your priority is, ‘Where am I going to get money to buy food and eat?’”⁶⁸ For those sex workers who have internalised the responsibility for disease prevention without necessarily having the wherewithal to be responsible, this adds an enormous burden of guilt, while failing to achieve the underlying goal of the prevention strategy (Jackie Pollock and Pornpit Puckmai, Empower, Thailand, personal communication, 2003).

Conclusion

The juxtaposition of Typhoid Mary and HIV Jane provides an opportunity to consider the idea of individual and professional responsibility in disease prevention strategies. In Mallon's case, the state required her to be a responsible member of the community, but effectively took away from her what she needed to act responsibly—a living wage. Mallon's refusal to accept the demands of the state was therefore arguably quite justified.⁷⁴ The position of HIV Jane bears striking structural similarities to Mallon. The disease is quite different, but the social forces are almost identical. Issues of poverty, gender, public fear and the law collide to marginalise and blame the already vulnerable.

HIV prevention strategies must look beyond high-risk groups and individual vectors, and treat the disease as a population problem, taking into account structural factors that constrain the actions of the individual or the group.⁴¹ Aspects of a model of “social miasma” may, in this regard, be promising.⁷⁵ An infectious disease like HIV is transmitted person-to-person, but social forces heavily pattern the transmission. The “bad airs” of a society that promotes what Sen characterised as “unfreedoms”, such as poverty, illiteracy and socially sanctioned violence, are an ideal cultural medium in which to promote the spread of HIV. In a fashion consistent with a comprehensive primary health care approach, strategies for disease prevention need to look beyond the high-risk individual to the forces that drive, control and pattern their actions.⁷⁶ Changing these structural factors will increase the agency of the individuals, allowing them to become a part of the prevention strategy and not simply the (moving) target of it.

Whichever control strategy is ultimately decided upon will rely on individuals acting responsibly, but which individuals? In an industry marked by the unequal distribution of power between clients and workers, the capacity and ability to dictate aspects of the commercial sexual transaction, including safe sex, most often reside with the client. Yet the attribution of responsibility in most disease prevention strategies fails to reflect this and is therefore likely to have only limited impact.⁷⁷ Societies demand responsibility from their citizens. It therefore seems reasonable that societies should support their citizens in achieving the agency to realise that responsibility.

Acknowledgements

Colleagues in India, notably Dr Jaysaree, planted the idea for this paper. This work was partially supported by a grant from the Ford Foundation. Daniel Reidpath is supported by a Senior Research Fellowship from the Victorian Health Promotion Foundation. The views expressed are those of the authors alone.

Notes

* Even in sub-Saharan Africa, where HIV is an infection of the general population and not just marginalised sub-populations, it is still strongly associated with the illicit relationships of mes petites, mistresses and sex workers,^{6978798081 69,78–81} in addition to vertical transmission and transmission in marriage.⁸²