mDisease: Cellphones Reshape Prostitution in India, and Complicate Efforts to Prevent AIDS

This NYTimes article has run an article suggesting that mobiles might be promoting the spread of disease as a result of the independence that the technology is providing to female sex workers (FSWs) in India.

It reports on a paper published in the Journal of AIDS & Clinical Research titled “Cellphones Reshape Prostitution in India, and Complicate Efforts to Prevent AIDS” that was authored by Bidhubhusan Mahapatra and Niranjan Saggurti from the HIV & AIDS Program, Population Council, New Delhi, Shiva S. Halli, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada and Anrudh K. Jain, Distinguished Scholar, Population Council, New York, USA following some research that was funded by a grant to the Population Council from the Bill & Melinda Gates Foundation through Avahan, its India AIDS Initiative.

My Thoughts

On reading the article and the report it’s clear that there are some significant misunderstandings being made that have contributed to the negative conclusions being drawn.

Indian FSWs are early adopters

Millions once bought sex in the narrow alleys of Kamathipura, a vast red-light district here. But prostitutes with inexpensive mobile phones are luring customers elsewhere, and that is endangering the astonishing progress India has made against AIDS… …The practice of FSWs using cell phones appears to be common in India, as the current study conducted in 2007-08 indicates that one-fourth of FSWs used cell phone to solicit clients

It seems the New York Times has woken up to the fact that the sex workers are using mobile for commerce but in 2012 it’s definitely not something new:

> Although the report is uncertain about it (suggesting that “The practice of FSWs using cell phones appears to be common in India“) it should be appreciated that this was in 2007 so it actually highlights how Indian FSWs are early adopters of mobile eg. in 2007 while the report showed that 25% of FSWs were already using mobile phones to solicit for business at this time India’s total mobile penetration rate was less than 21% (we’ve witnessed incredible growth over the last 5 years and today it’s at the 80% mark which would indicate that at least 95% of FSWs are mobile – if not multiSIM owners).

> in the UK this was so obviously apparent as far back as the 1990’s that by 1996 the majority of numbers appearing on vice cards were mobile numbers (largely as a result of BT’s efforts to block incoming calls to any of its numbers that were found to be appearing on cards) and by 2001 the display of any “vice cards” in phone boxes was made an arrestable/recordable criminal offence in the UK.

What’s so bad about increased independence and capacity of FSWs to self organise?

a brothel owner in Mumbai, has seen her profits decline as cellphones have made prostitutes more independent

I see this as similar to how online classifieds sites like Craigslist killed off the classifieds business models that so many printed newspapers used to rely upon. What I don’t see is why anyone cares about brothel owners who prosper from women selling their bodies.

Contrary to what’s being put forward by this report I can imagine there will be many positive developments (both to health and society) as a result of FSWs being given independence and the ability to self organise themselves to offer their services away from an environment that is so often linked to so many other criminal activities eg. child exploitation, money laundering, drug trade, etc.

Drawing inaccurate claims from the research

The newspaper article makes a few claims that the research report doesn’t support:

Studies show that prostitutes who rely on cellphones are more susceptible to H.I.V. because they are far less likely than their brothel-based peers to require their clients to wear condoms

Unfortunately the research doesn’t show this at all. What it does say is that “there is little evidence to date in India about the HIV risk behaviors of FSWs who use cell phone” and it makes a point of this in a call for the need for more research to be carried out.

Lost in translation

Several things mentioned in the newspaper article don’t make a whole lot of sense eg:

In interviews, prostitutes said they had surrendered some control in the bedroom in exchange for far more control over their incomes. “Now, I get the full cash in my hand before we start,” said Neelan, a prostitute with four children whose side business in sex work is unknown to her husband and neighbors. (Neelan is a professional name, not her real one.) “Earlier, if the customer got scared and didn’t go all the way, the madam might not charge the full amount,” she explained. “But if they back out now, I say that I have removed all my clothes and am going to keep the money.

So a FSW who has a husband, children and neighbors who are unaware of her occupation is somehow now in a better position to coerce/enforce payment from a customer in ways that weren’t available to a brothel owner?

FSWs are increasingly becoming hard to reach for outreach and providing STI services, which has been recognized as a programmatic challenge in the coming years

I fail to see how having a mobile phone makes FSWs hard to reach. Perhaps the public health workers need to work to establish more trust with these patients so that they are prepared to use the same channel that they use for soliciting customers to access healthcare services?

Quality of the data

From looking at the research I’m surprised at the lack of quality. Key things that jump off the page include:

> The report makes it clear that FSWs using mobile for soliciting are not a distinct group (eg. “irrespective of cell phone use for solicitation, FSWs also solicited at traditional places of solicitation like brothels, homes and streets“)

> Zero mention of ilicit drug use in surveys of FSWs (indicators listed included “inconsistent condom use, experience of STI-related symptoms, alcohol consumption prior to sex and difficulty in condom use negotiation“) which is clearly a major problem in India and is closely related to HIV rates among FSWs.

> In the last 5 years the mobile industry in India has transformed which in my opinion will have undermined the value of 5 year old data. In this case it’s likely that it’s introduced a substantial bias to any results because back in 2007 the early adopter group of mobile FSWs was a subset that was radically different to the profile of the majority of FSWs (the report claims they were “younger, better educated, never married and more dependent on income from sex work than others“).

> If the vast majority of Indian FSW’s now have mobile (which is reasonable to presume as the report has suggested they were early adopters in 2007) then it’s likely that the majority of FSWs are now “home based FSWs”. For this particular group in 2007 the report concludes that there are no additional HIV risk behaviours (eg. “Except for home-based, the use of cell phone had a multifold effect on FSWs’ HIV risk behaviors in other typologies of sex work“).

> Data accuracy: Before drawing positive conclusions about brothel working FSWs I think it’s worth appreciating that they would also have had more opportunity to be briefed about what to say when being quizzed about safer sex practices by “multilingual research assistants trained and experienced in different data collection techniques“.

Opportunity emerges from an appreciation of the possibilities of mobile

“The place where sex happens turns out to be an important H.I.V. prevention point,” said Saggurti Niranjan, program associate of the Population Council. “And when we don’t know where that is, we can’t help stop the transmission.”

I think it’s obvious that the Population Council needs to wake up to the change that has happened and the opportunity that they have. Instead of blaming the mobile it would be better if they realised that the location of the opportunity to educate has changed and it’s time for them to keep up.

Cellphones, those tiny gateways to modernity, have recently allowed prostitutes to shed the shackles of brothel madams and strike out on their own. But that independence has made prostitutes far harder for government and safe-sex counselors to trace. And without the advice and free condoms those counselors provide, prostitutes and their customers are returning to dangerous ways

If you understand mobile it’s actually now much more straightforward and can be more effective and easier to measure eg. What is it it about the way FSWs use mobile that makes them so hard to trace when the Indian legal system has so little trouble using it to prosecute criminals (90% of ALL crimes are already solved through the use of mobile phone records).

The Indian Government has the ability to access the call/message records of any mobile users and safe sex counselors can now reach these prostitutes in exactly the same way that their customers can (something that wasn’t possible before as they would’ve had to reach them via their brothel owners, by chance encounters, etc).

A few ideas:

The Indian Government and Safe Sex Counsellors need to work with people who understand the mobile industry so that they can better appreciate the challenges and opportunities that exist. Here are a few things I think they could do:

> Appreciate that the most significant opportunity is a preventative one. In regions of the world where sex is a taboo subject adult mobile content is having a huge impact on the way sexual habits are learnt. Whilst it’s a very difficult subject for politicians and telcos to approach there are massive opportunities to work with the mobile operators to ensure that only adult mobile video content that shows safer sex practices can be paid for and distributed over their networks.

> Work with mobile operators and device manufacturers to ensure that safe sex messages are embedded in content that is preloaded onto mobile phones. Preinstalling the Condom ringtone seems like a good starting point.

> Send safe sex messages to numbers that are being advertised by FSWs and require them to make an appointment to visit a community health worker at their convenience OR they will have incoming calls to their mobile account blocked.

My conclusion is that Governments and Public Health Authorities should look to mobile as an opportunity (mHealth) not a challenge (mDisease). Is there anything you’ve seen that could help them?

About David Doherty
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2 Responses to mDisease: Cellphones Reshape Prostitution in India, and Complicate Efforts to Prevent AIDS

  1. Pingback: Bill Gates: the proliferation of mobile devices hasn’t yet revolutionized life in developing countries « mHealth Insight: the blog of 3G Doctor

  2. Pingback: The Lancet “Mobile health-care information for all: a global challenge” | mHealth Insight: the blog of 3G Doctor

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