Immigration and travel policies: Whose health are we protecting?

On Oct. 30 2009, to the applause of the global public health community, U.S. president Barack Obama announced the repeal of an archaic and discriminatory policy that bans HIV positive people from entering the country. The ban will be officially lifted in early 2010.


Only ten other countries lay claim to similar travel bans, including Armenia, Brunei, Iraq, Libya, Moldova, Oman, Qatar, Russia, Saudi Arabia, South Korea and Sudan, according to the advocacy group Immigration Equality.


Upon Obama's announcement, UN General Secretary Ban Ki-Moon called on other nations to follow suit. Ban has pushed for repeals since the beginning of his term, stating that such bans "should fill us all with shame."


Even with the policy change, some restrictions will likely remain for people living with HIV hoping to settle in the U.S. The country's new policy will likely mirror that of Canada's, where those living with the virus can freely enter the country to visit, and cannot be excluded from settling purely because of their status. However, Canadian immigration policy does cite public health and significant financial burden as potential reasons for denying a person permanent residence or citizenship. According to Lorraine Lavalle of Citizenship and Immigration Canada, since 2002 only 126 of 2,567 HIV positive people applying for permanent residence have been denied status.


HIV travel and immigration restrictions point to the question of whether and when public health protection should trump human rights, and specifically freedom of mobility. Epidemiologists at national public health agencies are pegged with the job of keeping their country's citizens free from infectious diseases, and so are naturally concerned with ridding the border of pathogens. But in reality the policies enacted don't necessarily reflect the greatest public health threats, but rather the strength of powerful political ideologies, agendas and interest groups.


The history of the U.S. HIV travel ban demonstrates the power of politics over public health rationale. The ban was originally enacted in 1987 by the U.S. Department of Health and Human Services (DHHS). Despite the country's Public Health Service noting that "AIDS is not spread by casual contact which is the usual public concept of contagious," the Reagan administration pushed for the measure. Upon attempting to repeal it in 1991, the Department was blocked by Congress who, in 1993, officially made HIV the only medical condition explicitly listed under immigration law as grounds for inadmissibility. Through a series of maneuverings by Republican lawmakers, conservative Congress members argued that only Congress could repeal the ban, and galvanized their constituents and fellow members to ensure that this did not occur. For years, and despite domestic and international outcry, the law remained untouched, resulting in no major AIDS conference taking place on U.S. soil from 1993 onwards, an embarrassment to AIDS activists, public health experts and policy makers who touted the country as a global leader in the fight against the virus (after Obama's announcement the International AIDS Society declared that it will hold the bi-annual International AIDS Conference in Washington DC in 2012). In 2008, over 20 years after the original ban was enacted, former President George W. Bush removed HIV from the list of diseases of "public health significance" with regards to immigration. Obama's recent announcement will ensure that DHHS will fully repeal the measure.


According to UNAIDS executive director Michel Sidibe, "Placing travel restrictions on people living with HIV has no public health justification. It is also a violation of human rights." A policy statement by UNAIDS and the International Organization for Migration confirms, adding: "blanket exclusion of people living with HIV adds to the climate of stigma and discrimination." Upon repealing the ban Obama, too, conceited that the policy was "rooted in fear rather than fact."


In an ironic twist of fate and demonstration of the perverse nature of the travel ban, and despite incredible political, financial and human effort, the policy may have actually hindered any attempts at public health protection. By effectively making those living with HIV illegal, the policy encouraged positive people to hide their status while simultaneously acting as a disincentive for non-U.S. citizens to undergo testing and treatment. A 2006 study surveyed 1,113 HIV positive people, 31 per cent of whom had traveled to the U.S. Of those who had, only 14.3 per cent did so with the mandatory waiver needed to obtain a travel visa; the rest simply did not disclose their status. Furthermore, in order to maintain their faux-negative status, many went off life-saving antiretroviral therapy for the duration of their stay, increasing their chances of developing a drug-resistant strain of the virus and/or developing AIDS, both of which posits potentially devastating public health and financial costs. According to Global Health Magazine, "these restrictions have been found to harm public health and economic efforts...The ban...serves as a disincentive for immigrants to test for HIV, as a positive result could mean deportation."


Health-immigration policies not only perpetuate stigma against a specific illness, but also help to fuel (an often rampant) anti-immigrant mentality, as the newly arrived are targeted as vectors of diseases, undergoing intense scrutiny beyond that faced by a country's citizens. In addition to the repeal of the HIV travel ban, the U.S. recently announced that its contentious year-old requirement for young immigrant women to undergo vaccination for human papilloma virus (HPV) is set to be dropped as of Dec. 14, 2009. HPV is the most prominent sexually transmitted infection in North America and can cause cervical cancer. The policy, enacted under former President Bush in 2008, requires all female foreign nationals between the ages of 11 and 26 and attempting green card status to receive at least one of the three-shot series. At the time of the announcement only Gardasil, made by the U.S. pharmaceutical giant Merck, was available, costing upwards of $1,000 US for a three-shot series. Merck insists that it did not lobby for the policy.


While many U.S. states pushed for all school-age girls to undergo the prick, public outcry over the new vaccine's safety and effectiveness -- as well as its high cost and connotations of pre-marital sex-resulted in these campaigns being halted. Public health officials encouraged young women to receive the vaccine, but did not make this a requirement for school attendance. Reproductive rights and immigrant rights groups were infuriated with a policy put in place for foreign women only, claiming that it added a significant economic burden on the already expensive immigration process, as well as disregarding the concerns of immigrant women while respecting those of U.S. citizens.


Upon the policy's announcement, the National Coalition for Women's Rights claimed:


"The...requirement violates a woman's basic right to self-determination, creates additional barriers for immigrant families seeking adjustment of status, and unfairly forces immigrant women to subject their bodies to a new treatment with known side effects... This current policy, at best, sends the unfair message that only U.S. citizen women have the right to weigh the risks associated with Gardasil while immigrant women do not. At worst, the new rule is a continuation of an ugly history of using immigrant women as involuntary clinical trial subjects."


Spokesperson Maria Elena Garcia-Upson of the U.S. Citizen and Immigration Service retorted in defense of the policy, stating: "I think the public would agree that people who are coming into this country to adjust their status, if they have a contagious disease, we don't want that disease to be spread around." But HPV, like HIV, cannot easily be spread casually and is generally transmitted through sexual contact. All other vaccines required for immigration are aimed at combating infectious diseases transmitted through respiratory routes and considered to be highly contagious; the HPV vaccine is the only required that targets an STI.


There is little question that those living with HIV and immigrant women are highly stigmatized. Their low social status makes them poorly placed to effectively lobby for their rights or gain enough political traction and support to change discriminatory policies. While those prejudiced against or looking to benefit from both groups -- conservative law makers and their constituents in the case of the HIV travel ban, and anti-immigrant and pharmaceutical interests in the case of the HPV vaccine requirement -- can galvanize political and financial support, those fighting for the rights of people living with HIV and immigrant women are traditionally politically and financially less powerful, and are doubly burdened with fighting against deeply entrenched homophobia, xenophobia and sexism.


The repeal of the U.S. travel ban and HPV vaccine requirement are important and should be celebrated. Yet the necessary altering of two policies does not negate that public health has been historically co-opted to protect some groups at the expense of the human rights of others. Public health policies both implicitly and explicitly demonstrate society's prejudices; the groups we hold in the highest esteem and therefore consider in need of the greatest protection; and the power of certain interest groups.


The HIV travel ban and HPV vaccination requirement both affected certain groups of the American population in the name of protecting others: namely, U.S. citizens. But it wasn't their relatively infectivity that resulted in such policies, but rather the stigma attached to sexually transmitted infections, homosexuality and immigrants -- especially immigrant women. In reflecting upon these two important policy changes of 2009, we must understand the following: while epidemiologists may look purely at disease patterns, health policies do not, and instead are guided in part by power and prejudice.

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