Public health can spend a lot of time designing systems and waiting for people to enter them. The more effective approach is often the opposite: Go where people actually are, understand the reality of their lives, and bring the services to them.
About a decade ago, while traveling through Russia on a work trip for AIDS Healthcare Foundation, I saw one of the clearest examples of this at 11 p.m. on a frozen roadside in Siberia.
I could see steam from steady breathing rise into the night from four or five women standing along a secluded road outside Krasnoyarsk, Russia. Bare, slender legs braced against the cold while the rest of them disappeared into puffy jackets. A lone streetlight cast a dim amber circle as our van pulled up.
A couple of men in black leather jackets sat in a car tucked beneath some trees. They looked vigilant but relaxed when they recognized the vehicle. Community health workers were regular visitors, and everyone seemed to understand the arrangement: The “security detail” didn’t interfere with HIV-prevention work.
A local organization serving female sex workers had invited a colleague and me on one of its nighttime outreach runs. Cold apparently does not put much of a damper on sex work in this part of the world. Nor does it stop public health.
Svetlana was in the middle of her shift when we met. After hearing that we were visiting from AHF, she leaned toward me cheerfully and said, “Well then, go ahead and undress!”
I politely declined.
She was perhaps 30, and our conversation was easy and jovial. We asked what the women thought about HIV testing, condoms, and the outreach workers who visited them.
As we talked, one of the health workers invited another woman into our van for a rapid HIV test. A few minutes later, she stepped back into the cold night, tucking several strips of condoms into the pocket of her fur coat.
Svetlana said the women appreciated the service. The organization also worked with a nearby sexually transmitted infections clinic, where staff knew to expect referrals for treatment and follow-up.
Even the customers seemed familiar with the routine. A gray Lada—a boxy, Soviet-era sedan—passed us three or four times, its driver apparently unnerved by the unfamiliar people chatting with women who were trying to work. Eventually, courage or impatience won. He stopped, a passenger door opened, a brief conversation followed, one of the women got in, and the car disappeared into the Siberian night.
The remarkable thing was how unremarkable the whole interaction felt. There were no lectures, no shame, and no demands that anyone explain the choices that brought them to that roadside.
There was simply a test, some condoms, a connection to medical care if needed, and people willing to show up late at night in the cold because that was where the people they served happened to be.
Public health can become buried under strategies, targets, and technical language. At its best, the principle is much simpler: Meet people where they are, rather than waiting for them to come to you.
Denys Nazarov is the Director of Global Policy and Communication at AIDS Healthcare Foundation. He has been with AHF for more than 17 years.
