From 2003 to 2012, Ashok Alexander, an IIM Ahmedabad alumnus, worked in the area of HIV prevention among sex workers as the India head at Bill & Melinda Gates Foundation, after giving up his plush corporate job at McKinsey & Company, a global consultancy firm. There, he created Avahan, which became one of the biggest ever private prevention programme for HIV, covering six Indian states— Manipur, Nagaland, Maharashtra, Karnataka, Andhra Pradesh and Tamil Nadu. At present, he is the founder-director of the Antara Foundation, a Delhi-based non-profit working in the area of public health delivery in India.
In his latest book, 'A Stranger Truth: Lessons in Love, Leadership and Courage from India's Sex Workers,' he talks about his entry into public health sector, the challenges he faced when interacting with sex workers and why there still remains a lot to be done.
What was your strategy for educating sex workers on the use of condoms?
My strategy, in retrospect, was quite naive. I thought that the basic problem must be in the communication and logistics. I thought that if sex workers understood that they need to use condoms to keep themselves safe from contracting HIV, they would do it, but nobody had figured out actually how to communicate with them in an effective manner. So point one was to communicate the dangers of unprotected sex. Point two was to solve the problem of logistics involved in distributing the condoms to large populations of sex workers. How do you get the condoms from factory to depot to individual sex workers, etc.
But I soon discovered through field trips that in reality these were non-issues. Sex workers already knew what a condom was and that they had to use it to keep themselves safe. But, they were not interested. There were bigger, glaring issues which kept them from using condoms in the first place. First issue was that there was no safe place. Second, they had to face violence every time they would ask the client to use condoms. And both are linked. The reality was that sex workers didn't have a safe space in which they could rest when they were sort of off hours. Sex work usually started around 6 in the evening till late at night and the women would often come from the villages or wherever to the town around 2pm in the afternoon. They were on the streets and could be picked up anytime. Sex workers don't have safe spaces where they can take refuge. Therefore, to be able to create a space for them or create a community centre became like a magnet principle. Second, when we learnt that violence and unprotected sex were linked, we decided that it was time to deal with structural issues.
Do you feel that brothels are a great boon for sex workers?
From a public health point of view, especially HIV prevention, brothels are great. Because what happens is that all sex workers are at one place, and when it is concentrated in one place, it is easier to impose regulations. So we (the government) can tell them that condom usage must be enforced here. When there are no brothels, sex workers are on the streets. They can't be identified as such because they don't solicit openly in India and they are, for all practical purposes, invisible. That became a challenge of the kind that I had never seen before.
You said the government kept denying that there was a problem saying that Indian women were too moral to indulge in sex work
India, including the government of India and the general public, was in a state of denial, indifference and disinterest. So first was the feeling that the 'pure' Indian women would never indulge in sex work and that the Indian men would never go to a prostitute, citing the "purity" of our people. They said there must be a foreign agency at work. It is a concoction. It is a lie. Such was an attitude especially from those groups of self-appointed purists. So there was no compassion for sex work either.
The Vajpayee government was supportive
There were many people in the government who were not supportive. But when we met the prime minster himself, he was very supportive. He said, 'You'll get all the support you need from my government. I assure you that.' I give him a lot of credit for that.
How did your work in prevention of HIV among India's sex workers affect you and change you as a person
When I look at it as a timeline, a sequence of emotions run through. But I left McKenzie feeling confident, almost cocky, looking forward, excited to meet this new challenge. But when I saw the depth of poverty, I was shocked that I never knew that this India even existed. That then led to the feeling that all my presumptions about communications and logistics were solutions not going to work. I left a very secure career behind. It was a downer. Quite a downer. Then, when I began working with the community and seeing the kind of heroism and so on, the feeling became more positive. Within two to two-and-a-half years, the programme started becoming a success. It was wonderful after that. In the process, I got transformed as a person.
Which is your favorite chapter from the book you have written?
Somehow I like the chapter on truckers and I also like the two chapters in the second part—one on Kavita and the other on Sajid
Tell us about the lessons in leadership, love and courage that you learnt from from sex workers
Very few, in big corporate positions, will understand that sense of humour is a great weapon which can be used very tactically to win negotiations and disarm people and situations. Also, sex workers have raw courage, sometimes we must aim to imbibe. It is the plain courage to undertake life-altering risks, just like they do everyday. Also, I learnt what compassion means. Most textbooks on leadership preach being ruthless, but one must inherently be compassionate at all times.
What was the role payed by your wife in the shaping your book?
I will use the words—'tolerance, patience and understanding—to best describe her role and her support.
Was the antiretroviral treatment being administered that time?
Not when we started. It came much later, bit by bit. So, for most of the time we worked without it, to the best of our capacity.
Did you ever have to fight that desperate urge to help?
Yes. Once when I was in a room with a group of sex workers and I said to one of them that she must get herself tested as she may be HIV positive. She said, 'I may be having HIV but I can't get myself tested and confirm it because there is no treatment and I will lose my job and occupation'. So at the time I didn't know what to say to her in response and I ended up saying a very foolish thing. I said, I'll pay for the treatment and she said, 'are you going to pay for the treatments of all these women here and all the hundreds and thousands of them outside this room too? Are you crazy?' So that was the first time I learnt that I could not solve the problems on my own.
That is when you realised that it was a public health and not private charity
That is when I understood that public health programmes require some guts to do, and also you have to walk away from situations. You cannot give money to every single person.
You have spoken about the drug problem in the Northeast in your book
HIV prevalence was very high in Manipur and Nagaland. Many parts of those states had prevalence over two per cent which is considered to be epidemic proportions. The reasons for this is, one, because there was an insurgency movement which was happening in Manipur. They didn't allow restaurants, movies, and any form of avenue for entertainment that a youngster could opt for. There were no jobs either. The only good job was a government job and there were very few of those. So without a job, and no place for leisure, you are left with two options. You either join the underground or take a gun in your hand or get sucked in to drugs just because you're idle. Very pure form of heroin was available in those states. There is the golden triangle, which encompasses Cambodia, Laos, Burma where the poppy is cultivated and factories are manufacturing this stuff with or without the knowledge of governments in these places. Then this product ultimately reaches the US and the route is such that it is from Burma into Manipur through a town called More, from Manipur through Imphal all the way to Delhi and from there through routes in Afghanistan into Europe and from there to the United states. So given that Manipur was the first stop in the route, it was extremely low priced. One could get a hit of heroin for 50 rupees.