Elsevier

"Typhoid Mary" and "HIV Jane": Responsibility, Agency and Disease Prevention
Author(s): Kit Yee Chan and Daniel D. Reidpath
Source: Reproductive Health Matters, Vol. 11, No. 22, HIV/AIDS, Sexual and Reproductive Health:
Intimately Related (Nov., 2003), pp. 40-50
Published by: Reproductive Health Matters (RHM)
Stable URL: http://www.jstor.org/stable/3776045
Accessed: 11-12-2015 15:49 UTC

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 ? 2003 Reproductive HealthMatters.
REPRODUCTIVE
All rightsreserved.
HEALTH
ReproductiveHealthMatters2003;11(22):40-50 matters
ELSEVIER 0968-8080/03$ - see frontmatter
www.rhm-elsevier.com PII: S0968-8080(03)02291-2 www.rhmjournal.org.uk

"Typhoid and"HIVJane":
Mary"
Responsibility, andDiseasePrevention
Agency
KitYee Chan,aDanielD Reidpathb
a Research SchoolofHealth
Fellow, DeakinUniversity,
Sciences, Burwood, E-mail:
Australia. kityc@deakin.edu.au
DeakinUniversity,
FellowandSocialEpidemiologist,
Research
b Senior Australia

Abstract:Theconstruction of diseaserisksas knowable,calculableand preventablein dominant

social scienceand publichealthdiscourses has fostereda certainkindof logicaboutindividual
riskand theresponsibility forinfection.Diseasecontrolmeasuresthathavedevelopedout of this
logictypically failto recognisethesocio-structuralrootsof manyhigh-risk behavioursthatare
linkedto thespreadof infection. Instead,theyholdthediseasecarrier formanaging
responsible
his/her ownriskof infection of others,and relyon constrainingtheagencyof thecarrier (e.g.by
constraining movement, contact or In
occupation). occupations associatedwitha highriskof
infection, theidea of responsibility
of theactorimplicitlyraisesissuesof "professional
responsibility'Usingthecase of "Typhoid Mary"and a hypothetical case of "HIVJane",thispaper
exploressome of theproblemswithmakingsex workers responsiblefortheprevention of HIV
transmission. It arguesthatforthenotionof "responsibility"to makeanysense,theHIV-positive
personmustbe in a positionto exerciseresponsibility, and forthistheymusthave agency.
? 2003 Reproductive HealthMatters. All rightsreserved.

diseases,HIVtransmission
infectious
Keywords:healthpoliciesand programmes, (sexual),safer
sex promotion,
agency,sex workers

THE HIV/AIDSepidemichas been charac- missioncycle of the disease. Disease control

terisedas the greatestplague in human
history.The magnitudeof the epidemic
and the negativemoral connotationsassoci-
ated with the routes of transmission(e.g.
promiscuity,illicit drug use and sex work)
add dimensionsof complexityto the disease
preventionand controlstrategies.1-3In con-
temporary disease preventionmodelsand poli-
cies, the responsibilityof disease prevention
has been placed heavilyupon the hosts and
vectorsof the diseasewho makeup the groups
of individualsassociated with the routes of
disease transmission(also termedhigh risk
groups).4-7In such models, individuals are
treated as if they are independentof the
socio-economiccontextsin which they live,
and regardedas rationalactors in the trans-
effortstherefore are heavilyfocusedon edu-
cating the actors about the disease and their
to preventtransmission.
responsibility The as-
sumption is that informed individuals make
rational choices that will protectthemselves
and others.Actual punishment in the formof
imprisonment or implied punishmentin the
formof quarantineis available forthoseindi-
viduals who fail to "choose rationally".
In the epidemicof HIV/AIDS,sex workers,
along with other marginalisedgroups,have
becomethenewtargetsfordiseaseintervention.
The notionof actorresponsibility raises ques-
tions of professionalresponsibilitywhen it is
associatedwith the risksof HIV infectionin
sex workand theunderstanding of theriskand
its management.

40

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 KY Chan, DD Reidpath/ ReproductiveHealth Matters2003;11(22):40-50
Thispaperdevelopsand presentsa critiqueof
theidea ofindividualand professional responsi-
bilityin the controlof HIV,particularly as this
relatesto sex workers.Followingwriters suchas
Sen,8'9Nussbaum10 and Giddens,11 we situatethe
analysisof sex workerresponsibility withina
broaderframework ofstructure and agency12-a
termdefinedbroadlyas theautonomyorfreedom
availableto an individual,whichis "inescapably
qualifiedand constrained by thesocial,political
and economicopportunities thatare available".8
For the notionof professionalresponsibility
to makeany sense,thesex workermustbe in a
positionto exercisethatresponsibility,i.e. as an
actorshemusthavethefreedom and capacity(or
agency)to assumethatmantle.
A startingpointforthinking abouttheissuesis
theseemingly unrelatedcase of"TyphoidMary".
Her temporaldistance and the fact that the
disease involved was quite different permits
generalitiesabouttheroleof agencyand occu-
pationalresponsibilityin infectioncontrolto be
examined.Based on thecase ofMary,a modern
day (fictional)counterpartof "HIV Jane" is
constructed, and the lens of agencydeveloped
withTyphoidMarycanbe appliedtoHIV-positive
sex workersand theirrolein HIV prevention.
The case of TyphoidMary
Typhoidis a bacterialdisease transmitted by
ingestionof contaminated waterand food- the
oral-faecalroute- and chronicasymptomatic
carriersare a significant
reservoir
ofinfection.13
In thepre-antibioticera,thediseasehad a case-
fatalityrate of about 12%. In the West,this
was reducedto around 1% afterthe introduc-
tion of chloramphenicolin 1948. However,
modernoutbreaksof typhoidin the developing
worldcontinueto carrya case-fatalityrate of
around 10%/.13
MaryMallon- a cookworkingin NewYorkat
theturnof thelast century, who becamewidely
and unsympatheticallyknown as "Typhoid
Mary"-was one such asymptomatic carrier.14
In March 1906, Mallon was working for a
wealthybankerin New Yorkwhenmembersof
her employer'shouseholdcontractedtyphoid.
Mallon, on testingpositivefortyphoidbacilli
duringa sanitationinvestigation by New York
healthofficials,was detainedin an infectious
diseaseshospitalin relativeisolationfora period
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ofthreeyears.Shewas releasedon condition
that
she keptin contactwiththecity'shealthdepart-
mentand did notworkwithfood.Initially, fol-
lowingherrelease,she earneda livingwashing
clothes,but findingthe incomeinsufficientfor
herneeds,shereturned tothefoodindustryunder
theassumednameofMrsBrown.Sheworkedas a
cook in the Sloan Maternityhospitalforthree
monthsin 1915, duringwhich time 25 staff
contractedtyphoid(two of whomdied). When
she was identified,
she was returnedto the in-
fectiousdiseases hospitaland spent the next
23 yearsthere,untilherdeathin 1938.14
Agencyand TyphoidMary
The Mallon case is illustrative of a traditional
public health approachto disease prevention
and epidemiccontrolthat combinesmethods
of educationand punishmenton the disease
vector(real or potential).This approachdevel-
oped out of the contagiontheoryof disease
(a biological explanationof infection,which
itselfevolved into the germtheory)and won
out overthemoreenvironmentally and contex-
tuallyfocused miasma theory.15Essentially con-
tagion theorypositedthat an infectiveagent
thatpassedfroman infected individual(perhaps
througha vector,an intermediate host or an
environmental reservoir)caused disease to an
uninfected individual.This is in sharpcontrast
to themiasmatheory, whichpositedthatdisease
was caused by environmental exposureto "bad
airs".Underthe contagiontheory,disease pre-
ventionand controlis achievedby identifying
thoseindividualswho are infected(case identi-
fication),identifyingthose with whom they
have been in contact (contact tracing),and
testingand/orisolatingthe case and the con-
tactsto containfurther spreadof thedisease.
As illustratedin thecase ofTyphoidMary,in
thecontrolof epidemicsthisprocessoftenrelies
on coercivemeasures,includinglimitations on
movement,activityand humancontact.At its
mostextreme,the publichealthmeasuresrely
on the incarceration of infectiousindividuals.
However,more often,such restrictions merely
requiretheinfected individualto act and behave
in such a way as not to endangerothers.The
public health measuresused in many of the
affectedcountriesto controlSARS are a case
in point.16'17The responsibility for infection
41
 KY Chan,DD Reidpath HealthMatters2003;11(22):40-50
/Reproductive
controlrestsupontheinfectious individual,who
is obligedto safeguardothersagainstthedanger
of the self. The responsibilityof the Public
Health Authoritystartswith case detection,
tracingand testing,and ends (assumingcom-
pliance) with educatingthe rational,infected
individualsaboutthe disease and theirrespon-
As one healthofficer
sibility. fromMallon'stime
was quotedto say: "Informthemthattheyare
carriers.Mostpersonsso informed will care for
themselves in sucha way thattheywillnotbe a
menace to the public.'18This, indeed, is the
historicalexpressionof an assumptionof the
modernday information, educationand com-
municationstrategy-thatan informedactor
will makerationalchoices.19'20
Notwithstanding the importanceof informa-
tion and education,thisstrategyalone is often
insufficient.Theself-imposed on the
restrictions
disease carrieroftenreduce theiragency by
constraining the varietyof activitiestheycan
safelyengagein.Yet,withtheexceptionoflife-
long incarceration, the capacityof a personto
adhereto limitations on theiractivityand to as-
sumeresponsibility forothersrequires,counter-
intuitively,a sufficient
degreeof agencyto live
withinthoserestrictions.
Agency however,is not equally distributed
amongstthepopulation, wherebyeveryindivid-
ual can freelychoose and act. The broader
social, politicaland economicmilieuin which
people seek to act, and factorssuch as educa-
tion, wealth and tradeableskills-all interact
and influencetheextentoftheagencyavailable
to theindividual,and theirchoicesand actions.8
What the traditionalpublic health assump-
tionfailsto consideris theburdenits measures
impose upon the disease carrier.If the state
reducesa person'sagencyin such a way that
it inhibitstheircapacityto comply,the health
controlmeasureitselfis boundto fail.
Thiswas, arguably,whyfollowingherinitial
detention,the effortto restrainMallon from
handling food failed. In Mallon's case, the
restrictionmeanta changeof occupationfrom
food handlingto laundrywork.However,as a
poor, female,Irish Catholic immigrantto a
heavilygendered,ethnocentric and Protestant-
controlledcity,Mallon'slifeopportunities were
significantly restricted
even prior to her con-
tractingtyphoid.The coerced occupational
change only acted furtherto restrictthe al-
42
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ready limitedagency that Mallon had. This
burden,whichthe state failedto recogniseor
take responsibility for,eventuallyresultedin
Mallon failingto complywiththe occupation-
al restriction.Mallon saw her choices reduced
to: (1) stay in poverty,or (2) returnto her
formerprofession.Her returnto the kitchen,
whichresultedin a further outbreakof typhoid
and two deaths, triggeredthe even more
extremeand punitiveresponseof incarcerating
herforlife.'4
The example of Mallon is not peculiar to
herday.The modemday equivalentofMallon's
case was a youngwoman workingas a salad
makerinthelate 1980sat a fastfoodoutletinthe
US stateof Maryland,who was identified as a
typhoidcarrier.Once identified by healthoffi-
cials,shewas takenimmediately to an infectious
diseasesspecialistwho told herto go on leave
fromherjob, takethemedicationand comeand
see himagain. On herreturn visitshe explained
that the drivewas too long, the medication
wasn't doing anythingand she was going to
take herbs instead."Besides,"she added,"the
bastardsfiredme."18Whenaskedwhatshe was
doing next,this thoroughly modernMary re-
pliedthatshe was workingat anotherfastfood
outlet.Whatis instructive aboutthecase is that
her reactionto the loss of incomewas exactly
the same as Mallon's.Concealthedisease;seek
workelsewhere.Social responsibility and eco-
nomicinsecurity are not easilyreconciled.
The themesof agency,riskand responsibil-
ity in the control of typhoidare repeated,
althoughwith greatercomplexity, in the con-
trol of HIV. In many parts of the world,the
spreadof HIV remainsassociatedwith(though
not exclusively)marginalised social behaviours
such as injectingdrug use and promiscuous
sexual activity(usuallyattributed to men who
have sex with men and sex workers).21-23 As
with Mallon, disease preventionthat targets
sex workersalso raises issues of occupational
responsibilityand restriction.Consider,for
instance,the case of "HIV Jane"-a femalesex
worker.The example,and the discussionthat
follows,is aboutfemalesex workers, notbecause
males do not engage in sex workbut because
femalesmakeup themajority ofsexworkers, and
it is theywho are by farthe mostaffectedby
thediseaseprevention programmes and policies
regulating sex work.
 KY Chan,DD Reidpath HealthMatters2003;11(22):40-50
/Reproductive
The case of "HIVJane"
Jane Doe, aged 24, has been a sex workerfor
twoyears.She testedpositiveforHIV following
a recentconsultationat a clinicwhereshe was
screenedfor a range of sexually transmitted
diseases. Jane returnedto sex workthe same
day she receivedher testresults.She does not
informclientsof the testresults;however,she
does insiston the use of condoms,unless the
client pays extra, in which case she is less
insistent.
In manyrespectsMaryMallon and JaneDoe
are verydifferent. Theirdiseasesare different-
one viral,theotherbacterial;theroutesoftrans-
missionare dissimilar;Mallon's case occurred
almosta centuryago, whileJane'smightwell
have occurredyesterday. Yet theprinciplesthat
guide the disease preventionstrategiesthat
restricted the livelihoodof Mary,and restrict
Jane'stoday,arestrikingly similar.
Disease preventionand HIVJane
Much of the contemporary public health and
social science discourseson infectiousdisease
prevention drawon the calculusof risk,devel-
oping the idea of risk managementand risk
reduction (or harm minimisation).In what
Castel termed"autonomisedmanagementof
population",24epidemiologicalexpertiseand
quantitative capabilitygave riseto thepresump-
tion that the risks associated with infection
were "knowable,calculable,and thusprevent-
able".25The dominantdiscoursesdepicta direct
relation between individual action and the
safetyof the populationwiththe culturalsen-
sibilitiesof epidemiologysupportingand re-
inforcingthose of health education. In this
scenario,individualsare cast as the rational
self-governors of risk.By extension,the level
of riskborneby a societyis determined by the
action of individualcitizens,each of whomis
privatelyresponsiblefor the managementof
her/hisown risk.
Despitethe change of publichealthrhetoric
sincethetimeofTyphoidMary,theprincipleof
disease preventionremainslargelythe same.
Undercontemporary discourses,mostHIV pre-
ventionstrategiesassume,withsomevariation,
thatindividualsare rational,and thatinformed
individualsmakerationalchoicesthatwillpro-
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tectthemselvesand others.26'27 The AIDS Risk
ReductionModel (ARRM),forinstance,whichis
fairlytypicalof this approach,focuseson the
importanceof individualcognitiveprocesses
aroundknowledge,knowledgeacquisitionand
the mental algebra involved in risk-reward
calculations.28 The approachis highlyindividu-
alistic,and relieson a relativelyfacileaccountof
socio-structural factorsthataffectbehaviour.29
Thosewho "knowingly" place othersat riskare
to be blamedfortheirirresponsibility orjudged
irrational in their decision-making.25,30'31
Wheresex workis concerned,a layerof moral
inappropriateness is added by the association
betweenthe riskof infectionand sociallyun-
acceptablebehaviour.*
The state can, and oftendoes, demandthat
peoplewho are positivefora diseasetakeindi-
vidual responsibility fortheirinfectiousness-
and by implicationthe safetyof others.Where
individualsdo not take theirresponsibilities
seriously, the statehas the powerto intervene.
In theIndianstatesof Maharashtraand Kama-
taka,forexample,theHumanImmuneDeficiency
Virus(HIV) PreventionBill (1999) makesit an
offence knowingly totransmit thevirustoothers:
"No person who knows or in all reasonable
wouldhave knownthathe has HIV
probability
infection shall intentionallyorknowingly engage
in any practiceor behaviouror do or abstain
from doing any act, which places or has a
tendencyto place any otherperson at risk
ofHIV infection." S.4(1)32
"Everyperson cognizantof his beinginfected
withHIV shall withinsuch timeand in such
manneras maybeprescribed giveinformation of
such infectionto the DeputyDirectorhaving
jurisdictionoverthearea." S.8(1)32
In otherinstances,
theprohibition
on conductby
infectedpersonsis coveredunderthemoregen-
eral criminalor penal codes against causing
physicalharm.Section269 of theIndianPenal
Code states in part that a person who acts
*Evenin sub-Saharan whereHIV is an infection
Africa,
ofthegeneralpopulation andnotjustmarginalised sub-
populations, it is still
strongly associatedwiththeillicit
relationships of mespetites,mistresses and sex work-
ers,69'78-81in additionto verticaltransmission and
transmission in marriage.82
43
 KY Chan,DD Reidpath HealthMatters2003;11(22):40-50
/Reproductive
negligentlyin a way "...likelyto spread the
infection of any diseasedangerousto life"shall
be punishedwithup to six months'imprison-
mentora fine,orboth,and underS.270 a person
who actsmalignantly shallbe punishedwithup
to twoyearsin prisonor a fine,or both.33
A recent Scottishcourt decision similarly
confirmed the "knowingtransmission of HIV"
as an offence,when a man was sentencedto
fiveyears'imprisonment for"culpablyand reck-
lesslytransmitting HIV Withinthe
infection".34
50 statesof the US, numerouslegal provisions
also existto controltheconductofHIV-positive
people.35
Sexworkers,
riskandthelaw
The legal provisionsto preventthe transmis-
sion of HIV (necessarily)reducethe choicesof
theirtarget.Thus, when the legal provisions
seek to preventa personfromworkingwithin
theirprofessionand as a result,that person
suffersa loss of earningsand potentially their
entirelivelihood,thisis a seriousrestriction of
agency. Not unlike the treatment of Mallon,
measures that have specificallybeen taken
withHIV-positivesex workersto preventthem
fromworkingin theindustry includeimprison-
ment, detention in or other
quarantinefacilities,
legal or quasi-legalaction.36In placeswherethe
industryis regulated,manygovernments have
put in place separatelegislationto preventthe
"Janes"ofsex workfrominfecting "thepublic".
For instance,undertheAustralianstateofVic-
toria'sProstitution ControlAct (1994) S.20:
"A personmustnotworkas a prostitute during
any period in whichs/he knowsthat s/he is
infectedwitha sexuallytransmitted
disease."37
In anotherAustralianjurisdiction,New South
Wales:
"...public healthorderscan requirea person
suspectedof placing othersat riskof HIV in-
fectiontodo any one, or more,of thefollowing:
refrainfrom specifiedconducte.g. sex work,
undergospecifiedtreatment or counselling,
sub-
mit to supervision,undergo treatment,and
be detained..."38
Similarprovisionsexistelsewherein Australia,
underwhichHIV-positivesex workersare not
44
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permittedto continuetheiremploymentand
restrictionscan be placedon theirmovement, in-
cludinga curfew. 38
In so faras thelegislationassumesthatself-
controland disciplineare the keys to disease
prevention(and knowledgeand rationality in-
formself-control), the workeris giventhe re-
sponsibilityofmaking(orkeeping)herself "safe"
and "disease-free"forthe pleasureof the cus-
tomers.39 Underthisanalysis,theoccurrence of
HIV infection in sex workersmaybe understood
as a failureof theirresponsibility in self-care,
and in turn,thecare of theirclients.The choice
ofa workerto continueworkingoncesheknows
herselfto be HIV-positivemay be seen as a
violationofherprofessional Thus,
responsibility.
the HIV-positivesex workeris "deviant"and
construedas deliberately puttinghercustomers
at risk.This discourseof responsibility, more
than anything,reflectsthe need of the public
to createwhat Sacks describesas a "symbolic
boundarybetweenthestigmatised [sexworkers]
and unstigmatised[client]".40 By placing the
responsibilityand blame onto the sex workers,
thepublicgainsa senseofsafetyfromthe"vec-
tors of disease".Societyseeks to protectitself
fromits deviants,and yetthe deviantsarejust
the tail end of the distribution of the whole
population-only separable with the creation
of symboliccategories.41 The constructionof
the dangeroussex workeris uncannilyremi-
niscentof theFrankenstein-like transformation
of MaryMallon intothe monsterthatwas Ty-
phoidMary.14
Yet being responsible,as is requiredunder
legislationgoverningthe transmission of HIV,
is not a passive act. Responsibilityassumes
agency; at the veryleast a personmusthave
the capacityto act responsibly.Justas New
YorkhealthofficialsassumedthatMallonwould
be able to conductherlifewithoutworkingas a
cook,so governments todayassumesex workers
have alternative meansof financialsupport.Yet
thereasonsforwomenentering and leavingsex
workarecomplex,oftenbeyondtheircontroland
frequently economic.42'43Giventhis,thepivotal
questionforthe successof HIV prevention and
controlstrategiesinvolvingsex workersthen
becomes: do sex workershave agency?More
precisely,as requiredby the traditionalpublic
healthdiscourse, do sex workershavethelevelof
to
agencynecessary carry out theirprofessional
 KY Chan, DD Reidpath/ ReproductiveHealth Matters2003;11(22):40-50

responsibilityof safeguardingthemselvesand jaw dislocatedfourtimesin 10 monthsbecause

theircustomersfromthe riskof infection? This of thefrequencywithwhichshe was required,
also begs the questionof whether,even if sex oftenbyforce,to perform oral sex. Yetanother
workers do have sufficient
agency,they and not woman had herrightbreastcutso badlythather
theirclientsshouldbe held responsiblefortheir nipplehad to be re-attached surgically;and the
clients'health.44'45 listgoes on."47
The questionaround agency and sex work,
This situationmarksone extremealong a con-
although not necessarily discussed in that tinuum,from
language, has seen two broad positions ad- professionalswith an enormous
to exercise
choice(includingthechoice
vanced.44One holds the sex workerto be the capacity
to engagein sex workitself)to survivors, those
coercedvictim,theotherholdsherto be a person
whoseneedsare so immediateand so basic that
makingthebestchoice fromthe available (and their
Thereis of courseno agency is severelyconstrained.43 Where
perhapslimited)options.45 one sex workeris positionedis oftende-
sex workersituatedwithinone or any
quintessential terminedby structuralfactors,includingthe
otherposition,butvaryinglevelsof agencyand
environmentof where she works,
options.46 Considerthefollowingdescription of regulatory
the level of povertyin the environment and
someCostaRicansex workers:
personal factorssuch as abuse duringchild-
"Thelivesofthesewomenare markedbyviolent hood, drug dependency,minoritystatus (e.g.
abuseat thehandsofclients,policeofficers, and racial, ethnic or migrant),and her level of
partners. In the 10 months that I spent with educationand otherworkskills-all of which
thesewomen,notone day passed thatI did not affectthe conditionsin whichshe findsherself
witnessorsee theresultsofa violentattack.One working.43,45'48-53
woman,forexample,had herarmsburnedwhen Against the common perceptionthat sex
she was tied to a bedframe.Anotherhad her workersare vectorsand reservoirsof disease,

Truckstop,mainrouteto Malawiand Zimbabwe, 2002

Moatize,Mozambique,

45

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 KY Chan,DD Reidpath HealthMatters2003;11(22):40-50
/ Reproductive

HIV infection amongworkers at theupperendof would inhibittheirearningcapacityduringthe

thecontinuum is no higherthanforwomenwho
do notengagein sex work.54 Unfortunately, the
distributionof sex workerson thecontinuum of
agencyis heavilyskewed.Most sex workersin
the affluent Netherlands tendto have relatively
limitedagency; only a small proportionenjoy
the freedomsand choices associatedwith the
higherend ofthecontinuum.43 Theviolence,for
instance,describedin the Costa Rican quote is
repeatedin the literature on the economically
most well-offsettingsthroughto the most
deprived, e.g. in Britain,55Canada,56theNether-
lands43Sri Lanka57and SouthAfrica.48 Onlya
smallproportion of sex workersin thesestudies
experiencedlevels of agency consistentwith
workchoiceandjob satisfaction. Theexperience
of the restechoesthemesof poverty, threatsof
arrestand violence frommultiplesources(in-
cludingpolice,pimps,clientsand partners).
Evidenceof the relationship betweenagency
and responsibility in the daily practiceof sex
workerscan be foundin manyplaces,themost
relevantof which is perhapsthe negotiation
of condomusage, an area consideredessential
to HIV prevention.Numerous studies have
reportedthatthe powerstatusof an individual
affectsthenegotiation ofcondomuse.58Against
thecommonpresumption thatsex workers ought
to practicesafe sex, studies have repeatedly
reportedthat those who are in a positionto
negotiatesafe sex tendactivelyto complywith
safetystandardsand use condomsas routine
tools of the trade.59'60 For instance,in a study
conductedduringthe initialphase of the HIV/
AIDS epidemicin London,itwas foundthatin a
groupofsex workers recruitedat a clinic,fearof
AIDS had increasedtheircondomuse from54%
to 84%. Sex workersalso reported
a decreasein
sexualservicesand an increasein low-
high-risk
riskones. Similarpatterns have beenreported in
otherstudiesconductedin Britain,61,62 theUS63
and Australia.64'65
Studieshave also foundthatin circumstances
wheresafetyprecautionshad not been taken,
financialconcernsor theuse of forceby clients
was oftenresponsible.One studyof condom
use by sex workersin India,forinstance,found
thattheyoungerworkerswereless likelyto use
condomsthan the older ones. In an industry
whereyouthwas an importantcurrency, the
younger ones felt that the use of condoms
peak oftheircareers.66
Perhaps more centralto the discussion of
agency and responsibility is the fact that in
sex work, power largely resides with the
client.Researchhas repeatedlyidentifiedthe
unwillingness of clientsto engage in safe sex
as an importantfactorin commercialsexual
transactions, e.g. in India,67Britain40 and South
Africa.68'69Indeed,manystudiesshowthatcli-
entswill actuallypay moreforunsafesex than
forsafe sex,70whichhas to increasetheattrac-
tivenessof unsafesex to theeconomically vul-
nerablesex worker.71'72 Furthermore, unsafesex
is commonwhen clientsuse physicalforceto
overcomeworkers'unwillingness to engage in
unprotected sex.47'69 As one Johannesburg sex
workersaid: "Sometimeswe used condomsbut
sometimes theythrowthemawayand tryto beat
us".69In certaincultures, sex withoutcondomsis
viewedas a testament to a worker'scleanliness
(and theirHIV seronegative status),and clients
will therefore oftenrefuseto engage in sexual
transactions withworkerswho insiston using
condoms.63'67 Consequently, some sex workers
have no choice but to put theirown healthat
risk,as wellas theirclients'. Themoredependent
the workersare on sex workto providetheir
income, the less choice they have in safety
negotiations. Betweenimmediatephysicalsur-
vival and long-term healthrisks,thedecisionis
rationallymadein favourofimmediate survival.
The similarities with Mary Mallon are almost
palpable.As Thomasexpressedit:
"...no sex workerforces a clientto have sex,
protectedor unprotected, whereasthreatsof,or
rape,in order
actual,physicalviolence,including
to obtainunprotected sex are a far fromrare
experience,especiallyfor womenworkingthe
streets."73
In lightofthedisadvantaged workenvironment
of many sex workers,the riskof contracting
HIV mustnecessarily be weighedas just one of
many occupational hazards. For the moredis-
advantaged sex workers,even in situations
wherechoice applies,the concernsof everyday
life,combinedwiththeknowledgeofthelengthy
asymptomatic periodof the disease,allows the
riskof HIV infection to assumea relativelylow
positionin the list of life'spriorities.
The per-
ceivedmaterialbenefits ofsex workers'high-risk

46

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All use subject to JSTOR Terms and Conditions
 KY Chan,DD Reidpath HealthMatters2003;11(22):40-50
/Reproductive

behavioursthus outweighthe risksof HIV in- regard,be promising.75 An infectiousdiseaselike

fectionand the riskof gettingcaught.One sex
workerquotedbyVargasaid: "Ifyou startmak-
inghealthissuesa priority and areverystrictin
termsof safe sex... you becomea starvingsex
workerveryquickly."68 Anothersaid,"Whenyou
wake up in themorning, they[sic]do notthink
about how to preventAIDS and stay healthy.
Yourpriorityis,'Wheream I goingto getmoney
to buy food and eat?' ,68 For those sex workers
who have interalisedtheresponsibilityfordis-
ease prevention withoutnecessarilyhavingthe
wherewithal to be responsible,
thisaddsan enor-
mousburdenofguilt,whilefailingto achievethe
underlyinggoal of the preventionstrategy
(JackiePollockand PompitPuckmai,Empower,
Thailand,personalcommunication, 2003).
Conclusion
The juxtapositionof TyphoidMary and HIV
Jane providesan opportunity to considerthe
idea of individualand professional
responsibil-
ityin diseaseprevention In Mallon's
strategies.
case, the staterequiredherto be a responsible
memberof the community, but effectivelytook
away fromherwhat she neededto act respon-
sibly-a livingwage. Mallon'srefusalto accept
thedemandsofthestatewas therefore
arguably
quitejustified.74The positionof HIV Janebears
strikingstructuralsimilaritiesto Mallon. The
disease is quite different,
but the social forces
are almostidentical.Issues of poverty,gender,
public fearand the law collideto marginalise
and blamethe alreadyvulnerable.
HIV preventionstrategiesmustlook beyond
high-riskgroups and individualvectors,and
treatthediseaseas a populationproblem, taking
intoaccountstructural factorsthatconstrain the
actionsoftheindividualorthegroup.41 Aspects
of a model of "social miasma" may, in this
HIV is transmitted person-to-person, but social
forcesheavilypattern thetransmission.The"bad
airs" of a societythatpromoteswhatSen char-
acterisedas "unfreedoms", such as poverty, illi-
teracyand sociallysanctionedviolence,are an
ideal culturalmediumin whichto promotethe
spreadof HIV. In a fashionconsistentwith a
comprehensive primaryhealth care approach,
strategiesfor disease preventionneed to look
beyondthehigh-risk individualtotheforcesthat
drive,controlandpattern theiractions.76Chang-
ing these structuralfactorswill increase the
agency of the individuals,allowing them to
become a part of the preventionstrategyand
notsimplythe(moving)targetof it.
Whichevercontrolstrategyis ultimately de-
cided upon will relyon individualsactingre-
sponsibly, butwhichindividuals?In an industry
markedby the unequal distribution of power
betweenclientsand workers,the capacityand
abilityto dictateaspectsofthecommercial sex-
ual transaction, includingsafe sex, mostoften
reside with the client.Yet the attributionof
in mostdiseaseprevention strate-
responsibility
gies failsto reflect
thisand is thereforelikelyto
have only limitedimpact.77Societiesdemand
fromtheircitizens.It therefore
responsibility
seems reasonablethatsocietiesshouldsupport
theircitizensin achievingthe agencyto realise
thatresponsibility.
Acknowledgements
ColleaguesinIndia,notablyDr Jaysaree,
planted
theideafor thispaper. Thisworkwas partially
supportedbya grantfrom theFordFoundation.
Daniel Reidpath is supported by a Senior
ResearchFellowshipfromthe VictorianHealth
Promotion Foundation.Theviewsexpressedare
thoseof theauthorsalone.

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Resume
Le discoursdominantdansles sciencessocialeset
la sante publiqueestimequ'on peut connaitre,
calculeretprevenirles ce qui
risquesdemorbidite,
a encourageune certainelogique sur le risque
individuelet la responsabilitede l'infection.
Les mesures de lutte contre la morbidit6
issues de cette logique meconnaissent les
origines socio-structurellesde beaucoup de
comportements a haut risque. Au contraire,
elles estimentqu'il incombeau <porteurde la
maladie? de gererle risque qu'il a d'infecter
autrui,et veulent limiterl'action du porteur
(p. ex. en restreignant ses mouvements,
ses contacts ou ses occupations). Dans des
professions associ6es a un risque eleve
d'infection, lid6e de la responsabilit6 du
porteur souleve implicitementla question
de ((responsabiliteprofessionnelle?.Utilisant
le cas historique de (Typhoid Mary> et un
cas inventede (VIH Jane? l'articleetudie les
problemessouleves quand on responsabilise
du sexe de la prevention
les professionnel(le)s
de la transmissiondu VIH. II affirmeque pour
que la notionde (responsabilite)ait un sens,
la personneseropositivedoit pouvoir exercer
sa responsabiliteet donc avoir une latitude
d'action.
Resumen
En los discursosdominantesde las ciencias
sociales y la salud piblica se han construido
los riesgos de enfermedadcomo elementos
que se pueden conocer, calcular y prevenir,
fomentandoasi una cierta l6gica acerca del
riesgo y la responsabilidad individual con
respectoa la infecci6n.Las medidasde control
de las enfermedades que se han desarrolladoa
partirde estal6gicadesconocenlas raicessocio-
estructurales demuchoscomportamientos de alto
riesgovinculadosa la propagaci6nde infecci6n.
Al contrario,dichas medidas consideran al
"portadorde la enfermedad" el responsablede
manejarsu propioriesgode infectara otros,y
pretenden el movimiento,
restringir contactoso
actividades del portador.Con respectoa las
actividadesasociadas con riesgode infecci6n,
la idea de la responsabilidaddelportador plantea
asuntos de "responsabilidad profesional".
Usando el caso hist6ricode "Maria Tifoidea"y
el caso hipoteticode una tal "JuanaVIH", este
articulo examina algunos de los problemas
inherentes en responsabilizara las trabajadoras
del sexo porla prevenci6nde la transmision del
VIH. Planteaque para que tengasentidola idea
de la "responsabilidad", la personaviviendocon
VIH debe estar en una circunstanciaque le
permitahacerseresponsable.

50

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