Elsevier

Social Science & Medicine

Volume 64, Issue 2, January 2007, Pages 496-507
Social Science & Medicine

The necessary contradictions of ‘community-led’ health promotion: A case study of HIV prevention in an Indian red light district

https://doi.org/10.1016/j.socscimed.2006.09.009Get rights and content

Abstract

Health promotion interventions with marginalised groups are increasingly expected to demonstrate genuine community participation in their design and delivery. However, ideals of egalitarian democratic participation are far removed from the starting point of the hierarchical and exploitative social relations that typically characterise marginalised communities. What scope is there for health promotion projects to implement ideals of community leadership within the realities of marginalisation and inequality? We examine how the Sonagachi Project, a successful sex-worker-led HIV prevention project in India, has engaged with the unequal social relations in which it is embedded. Our ethnographic study is based on observation of the Project's participatory activities and 39 interviews with a range of its stakeholders (including sex worker employees of the Project, non-sex-worker development professionals, brothel managers, sex workers’ clients). The analysis shows that the project is deeply shaped by its relationships with non-sex-worker interest groups. In order to be permitted access to the red light district, it has had to accommodate the interests of local men's clubs and brothel managers. The economic and organisational capacity to run such a project has depended upon the direct input of development professionals and funding agencies. Thus, the ‘community’ that leads this project is much wider than a local grouping of marginalised sex workers. We argue that, given existing power relations, the engagement with other interest groups was necessary to the project's success. Moreover, as the project has developed, sex workers’ interests and leadership have gained increasing prominence. We suggest that existing optimistic expectations of participation inhibit acknowledgement of the troubling work of balancing power relations. Rather than denying such power relations, projects should be expected to plan for them.

Introduction

Contemporary health policies prescribe community ownership and leadership as essential components of effective health promotion with marginalised groups. However, the positive language of participatory policies may not prepare community projects for the significant dilemmas and challenges which they encounter upon implementing participation. This paper focuses on the dilemma of the extent to which more powerful groups outside of the focal participating group may be permitted to exert influence over a project. By showing how the condition of marginality in fact forces participatory projects to involve and to adapt to more powerful groups, this paper aims to contribute a realistic conceptualisation of the scope for such projects to be genuinely ‘community-led’. Our argument is made through a case study of a sex-worker-led project based in Kolkata (Calcutta), India. To set the context for the case study, we briefly outline contemporary controversies over participation before describing current participatory health promotion for sex workers in India.

Section snippets

The disputed role of community participation

At its inception, community participation as an approach to health and development projects was framed as a critical counter to the power inequalities of the ‘top-down’ imposition of development programmes. Thus, for instance, the World Bank's (1997) Participation Sourcebook explained its new ‘participatory stance’ by contrast to the old ‘external expert stance’. Based on important critiques of an undemocratic and unequal development process which had often produced locally unpopular and thus

Conceptual approach: interdependencies between unequals

Dominant conceptualisations of community may bear some of the responsibility for the polarised interpretations of community participation outlined above. While the conceptual debate is often posed as being between ‘locational’ definitions of community, based in a geographical place, and ‘relational’ definitions, based on shared identities or interests (Heller, 1989), both definitions are fundamentally similar in that they are based on similarity or homogeneity among community members. The

Community-led HIV prevention for Indian sex workers

Interventions with sex workers are a cornerstone of India's response to the HIV pandemic, given that the majority of HIV infections are thought to be acquired through unprotected heterosexual intercourse, and that traditionally, few Indian women other than sex workers have opportunities to have multiple sexual partners (Nagelkerke et al., 2002). The active involvement of sex workers is widely considered a necessary component of such interventions (Chattopadhyay & McKaig, 2004; O’Neil et al.,

Methods

The Sonagachi Project's relationships with other powerful actors is one aspect of a larger study which aimed to understand how the Project achieves its successes. Ethnographic research, comprising observation and interviews was carried out at the Project during May 2000, June–December 2001, September 2002, and July 2005. This paper draws on interviews with 19 sex workers employed by the Project, 7 non-sex-worker professional staff, and 13 other local people (landladies, madams, sex workers’

Relations with local clubs

The Sonagachi Project is not the only group seeking to provide organisation and orderliness in Kolkata's red light districts. In many areas, local men's social clubs have traditionally occupied a leadership role. These clubs draw their membership from the men of the red light area, who are often the unemployed sons of sex workers. The clubs are centres of social activity for the men, they organise local events such as festival celebrations, and they see themselves as protecting the orderliness

Relations with madams

Madams own or rent the rooms within which sex workers live and work, provide them with meals, exert control over their working conditions, and receive a fixed 50% of their earnings. With sex workers, madams share an economic interest in the sale of sex taking place without trouble being caused by clients, police or local clubs. However, sex workers’ interests in their health and autonomy can conflict with madams’ economic logic that the more clients entertained, the greater the income,

Relations with health and development professionals

While the design and implementation of Project activities depend heavily on sex workers’ contributions, it is fair to say that the Project would not exist without the significant input of non-sex-workers, including health professionals, social workers, and community development activists. Several years prior to the Project's initiation, a group of sex workers in Sonagachi had come together with the aim of collectively addressing the violence and exploitation which they suffered. They achieved

Relations with funding agencies

The final non-sex-worker interest group to be considered here comprises the funding agencies which make possible the staffing and resourcing of the clinics, offices, and activities that make up the Project. As an economically impoverished group, sex workers depend upon the financial input of funding agencies for their Project to exist. The competitive and insecure funding environment means that Project activities are oriented to funding agencies as one of their important audiences.

Fortunately

Conclusions

In this paper, we have examined the involvement of non-sex-workers in the ‘community-led’ Sonagachi Project. We have done so with the aim of understanding the prospects for interventions to be genuinely led by the interests of marginalised groups. Our analysis has shown that the Project is driven, not simply by the community of sex workers, but by a complex set of negotiations between sex workers, local clubs, madams, professionals and funding agencies. The interests of powerful local men and

Acknowledgements

We would like to sincerely thank the members and associates of Durbar Mahila Samanwaya Committee and the STD/HIV Intervention Programme, who gave so generously and enthusiastically of their time. Catherine Campbell has inspired and guided the work presented here. Thanks to Alex Gillespie and Chik Collins for critical commentary. Financial support for this work was provided by an ESRC Postgraduate Studentship, a Research Studentship from the London School of Economics and an award from the

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