Improving LGBT Health Education in South Africa: Addressing the Gap

I first became interested in the topic of lesbian, gay, bisexual, and transgender (LGBT) health care and health education while working as a country lead for the Presidential Emergency Plan for AIDS Relief (PEPFAR). During my time there I had the opportunity to travel to South Africa and understand their community and health care system a bit better, with an emphasis on their HIV/AIDS epidemic. This post focuses on the LGBT history in South Africa, recent developments, addressing that there is a gap between homophobia and non-judgmental care, and the importance of health care workers understanding LGBT health education.

More and more countries around the world are opening their arms to welcome and embrace LGBT pride. South Africa has one of the world’s more progressive constitutions which legally protects LGBT people from discrimination, although current research indicates that they continue to face discrimination and homophobia in many different facets of life. The most recent milestone occurred in 2006 when the country passed a law to recognize same-sex marriages. Nevertheless, LGBT South Africans particularly those outside of the major cities, continue to face some challenges including conservative attitudes, violence, and high rates of disease. As the country continues to grow there seems to be an increase in LGBT representation (with approximately 4,900,000 people identifying as LGBT) whether it is through activism, tourism, the media and society or support from religious groups. So, what about LGBT health education? Continue reading “Improving LGBT Health Education in South Africa: Addressing the Gap”

Policy on #HIV related travel restrictions adopted by @WFPHA_FMASP at #WCPH2017 now posted

After APHA adopted its permanent policy statement on HIV-related immigration restrictions that we submitted at last year’s Annual Meeting, the IH Section worked with APHA’s WFPHA liaison, Dr. Deborah Klein-Walker, to submit a corresponding policy proposal on behalf of APHA to the World Federation of Public Health Associations, which held its 15th World Congress on Public Health this month in Melbourne, Australia. The proposal was accepted and passed by the WFPHA Policy Committee at the meeting, and has now been posted the website (PDF). The text of the policy (excluding references) is below.

Scientific evidence and treatment needed to combat the spread of HIV – not ineffective travel bans

Submitted by the American Public Health Association
(Contact person D. Walker)

Introduction
HIV-related restrictions against entry, stay, and residence remain common around the world. Various countries have policies that mandate HIV testing of all or certain groups of foreign nationals as a condition of obtaining a visa for employment. These policies have no basis in science and violate migrant workers’ human rights to confidentiality and informed consent to testing, exposing them to exploitation by their employers. According to UNAIDS, 35 countries currently have official HIV-related travel restrictions. Furthermore, HIV-related travel restrictions against foreign nationals have been shown by international treaty bodies, international legal scholars, and human rights organizations to constitute discrimination based on race, ethnicity, and/or country of origin.

Scope and Purpose
Restrictions on travel, immigration, or residence related to HIV status are a violation of the principles of nondiscrimination and equal treatment in all international human rights laws, treaties, and agreements. The International Covenant on Civil and Political Rights guarantees the right to equal protection under the law, free from discrimination based on race, color, sex, language, religion, political or other opinion, national or social origin, property, birth, or other status, and the UN Commission on Human Rights has determined that this includes discrimination based on health status, including HIV infection. According to the Siracusa Principles on the Limitation and Derogation Provisions in the International Covenant on Civil and Political Rights, while international human rights law allows governments to restrict rights in cases of emergency or serious public concern, the restrictions must be the minimum necessary to effectively address the concern – and HIV-related travel restrictions have been overwhelmingly ruled as both overly intrusive and ineffective public health policy. Within such restrictions, compulsory HIV testing is a serious violation of numerous human rights principles, including the right to bodily integrity and dignity. The accompanying deportation and/or loss of employment and residency status of HIV-infected migrants that frequently accompanies such testing violates the rights of PLWHA to privacy, work, and appropriate medical care. The International Labour Organization (ILO) has specifically stated that neither HIV tests nor private HIV-related personal information should be required of employees or job applicants.

Despite this robust evidence base, according to UNAIDS, 35 countries currently have official HIV-related travel restrictions openly acknowledged and enforced by the government. These restrictions vary from outright entry bans, which bar PLWHA from entering the country, to restrictions on stays longer than a specified period of time or to obtain employment visas or residency status. Others have inconsistent policies and/or intentionally misrepresent their policies with HIV-related restrictions. Such policies and practices, and the number of migrants impacted by them, are difficult to track because of differing or ambiguous definitions and a lack of data. Some of the most restrictive policies subject immigrants to mandatory HIV testing, either when applying for residency or for an employment visa, which is frequently required by states for legal residency.

The two primary justifications provided by governments for mandatory HIV tests for migrant workers and other HIV-related travel restrictions are to protect public health and reduce the cost burden on the country’s healthcare system imposed by providing HIV care services to foreign nationals. While countries have the right to employ measures to protect their populations from communicable diseases of public health concern, HIV is not transmitted by casual contact, meaning there is no scientific basis for attempting to control its spread via immigration policies. Furthermore, countries that do not have HIV-related travel restrictions have not reported any negative public health consequences compared to those that do, and recent analysis suggests that even migration from countries with generalized HIV epidemics does not pose a public health risk to destination countries.

In fact, immigration policies banning or restricting entry or employment based on HIV status often have the opposite effect of their protective intention, causing direct harm to the health of both of immigrants and citizens. They marginalize PLWHA, regularly discourage people from accessing HIV testing and treatment, and reinforce stereotypes and discriminatory attitudes against PLWHA in the general population. Regulations requiring HIV tests of immigrants can promote the idea that foreigners are dangerous to the national population and a public health risk, as well as creating a false sense of security by reinforcing the notion that only migrants are at risk for infection. Additionally, such attitudes can adversely impact the host country’s own HIV epidemic, as citizens who are unaware of their HIV-positive status, underestimating their own HIV risk and avoiding testing due to stigmatization, are more likely to transmit the virus to others, driving up infection rates.

State-enforced HIV screening of migrants costs far more than it saves in treatment costs. Screening travelers and migrants for HIV is impractical and expensive.[5][13][19] Labor migrants (both regular and undocumented) bring significant economic benefits to their host countries, in addition to themselves, and this cost-benefit balance remains even when migrants are HIV-positive and rely on the host country’s health care system for treatment and support.

Fields of Application:

  • National public health associations and their members
  • Human rights and HIV advocacy groups
  • UNAIDS
  • The World Federation of Public Health Associations

Action Steps:

The WFPHA joins with UNAIDS, the World Health Assembly, and other HIV and human rights organizations (e.g., Amnesty International, Human Rights Watch, ILO) to call on all countries that still maintain and/or enforce HIV-related restrictions on entry, stay, or residence to eliminate such restrictions, ensuring that all HIV testing is confidential and voluntary and that counseling and medical care be available to all PLWHA within its borders, including migrants and foreign nationals.

The WFPHA affirms the following principles:

  • All people have the right to confidential and voluntary HIV testing and counseling.
  • Persons living with HIV/AIDS (PLWHA) have the right to privacy, to work, and to appropriate medical care.
  • All HIV-related travel and immigration restrictions currently in place should be removed.
  • Agencies and businesses who employ foreign nationals should not use HIV tests as a means to discriminate against potential employees.
  • Governments should provide HIV prevention and treatment services that are equally accessible to citizens and foreign nationals.
  • Migrant workers should have access to culturally appropriate HIV prevention and care programs in languages that they can understand.

The WFPHA recommends that:

  1. Public health associations in every country should:
    1. Develop policies opposing HIV-related travel restrictions;
    2. Document and/or support human rights and HIV advocacy groups in documenting immigration policies that explicitly discriminate, or allow employers to discriminate, against migrants based on HIV status;
    3. Document and/or support human rights and HIV advocacy groups in documenting any HIV testing practices that are not voluntary or confidential;
    4. Inform their members and the public that HIV-related travel restrictions and compulsory HIV testing of foreign nationals is a violation of human rights and does not protect public health or reduce health care costs; and
    5. Advocate for the removal of any and all HIV-related travel restrictions enforced or condoned by their country governments.
  2. UNAIDS should take steps to ensure that its protocols to research and investigate countries’ HIV-related travel restrictions are sufficiently thorough by monitoring and documenting any reported instances of HIV-related discrimination targeting immigrants, particularly when presented with evidence demonstrating that recognition of a country’s removal of HIV-related travel restrictions is unwarranted, in order to ensure that governments are not able to misrepresent their policies in order to gain undeserved recognition for supporting human rights with regard to HIV/AIDS.

WFPHA supports the removal of all HIV-related travel restrictions and travel related mandatory testing.

APHA Component letter to @UNAIDS: South Korea’s #HIV immigration restrictions

After two years, two APHA policy statements (one interim and one permanent), dozens of e-mails (and perhaps just as many drops of blood, sweat, and tears), and a few phone calls, we have finally sent a letter to UNAIDS urging it to revoke its recognition of South Korea’s status as a country without any HIV restrictions – until it actually produces and enforces policies that actually reflect that status.

Heartfelt thanks to Dr. Laura Altobelli, our Section Chair; Mona Bormet, our Advocacy/Policy Committee’s advocacy coordinator; and all of the Components who signed on to this hard-won letter (and the policy proposals that led up to it):

If there is one thing I have learned through this odyssey, it is that the work of advocacy is exhausting. It takes the old adage of “marathon not sprint” to a whole new level. The patience required to work within the boundaries, and according to the rules, of whatever framework you are trying to leverage to produce change can be maddening at times, but I suppose that is the inevitable price we pay to work with others. The larger your advocacy “vehicle” is, the more likely it is to be effective, but the more restrictions you have to work within. Or around, as the case may be.

On a more positive note, we also got a corresponding policy approved for adoption by the World Federation of Public Health Associations at their assembly (which kicked off today!). It will be posted here as soon as it is published, with potentially more letters to follow. Stay tuned.

The full text of the letter, followed by an embedded PDF, is below.

Dear Executive Director Dr. Michel Sidibé:

On behalf of the International Health Section of the American Public Health Association (APHA), we write to notify you of a new APHA policy statement, “Opposition to Immigration Policies Requiring HIV Tests as a Condition of Employment for Foreign Nationals,” which was adopted at the Association’s 2016 Annual Meeting.1 As you may know, APHA was founded in 1872 and is the oldest organization of public health professionals in the world. It has a long-standing commitment to promoting global health and protecting human rights, recognizing that these two go hand-in-hand.

HIV-related travel restrictions are recognized as a violation of human rights and have been well-established as ineffective at reducing the spread of HIV. Such policies further marginalize people living with HIV/AIDS (PLWHA), discourage people from accessing HIV testing and treatment, and reinforce stereotypes and discriminatory attitudes against PLWHA in the general population. According to APHA’s policy statement, “[immigration] policies that mandate HIV testing of [foreign nationals] as a condition of obtaining a visa for employment…have no basis in science and violate migrant workers’ human rights to confidentiality and informed consent to testing, exposing them to exploitation by their employers.”

Increasing awareness of the harms of mandatory testing and accompanying pressure from multilateral institutions and human rights advocates has begun to prompt countries to lift travel bans and change their immigration policies. We recognize that UNAIDS has been instrumental in this effort and laud the organization both in its leadership on this initiative and the progress that it has made. APHA’s policy statement specifically cites the work of the UNAIDS International Task Team on HIV-related Travel Restrictions and notes that “[a]dvocacy efforts using [the Task Team’s findings] have resulted in several countries loosening these restrictions or, in some cases, dropping them entirely: the number was reduced from 59 to 45 countries in 2011 and, as of September 2015, to 35.” APHA’s policy statement calls on UNAIDS and others to “continue to call on all countries that still maintain and/or enforce HIV-related restrictions on entry, stay, or residence to eliminate such restrictions, ensuring that all HIV testing is confidential and voluntary and that counseling and medical care be available to all PLWHA within its borders.” We urge UNAIDS to continue this work to make further progress in the remaining countries that enforce HIV travel restrictions.

The policy statement also recommends that “UNAIDS take steps to ensure that its protocols to research and investigate countries’ HIV-related travel restrictions are sufficiently thorough by monitoring and documenting any reported instances of HIV-related discrimination targeting immigrants, particularly when presented with evidence demonstrating that recognition of a country’s removal of HIV-related travel restrictions is unwarranted, in order to ensure that governments are not able to misrepresent their policies in order to gain undeserved recognition for supporting human rights with regard to HIV/AIDS.”

One such example of misrepresentation of HIV-related immigration policy can be found with the Republic of Korea (ROK), which subjects foreign nationals applying for visas to work or study under several visa categories to mandatory HIV testing.2,3 Recent decisions by the UN Committee on the Elimination of Racial Discrimination4 and the National Human Rights Commission of Korea5 both confirm the ongoing existence and enforcement of mandatory testing for E-2 visa applicants and recommend that they be struck down. Unfortunately, despite this discriminatory requirement, ROK representatives declared at the 2012 International AIDS Conference that their government had removed all HIV-related travel restrictions and, as a result, the country was granted “green” (restriction-free) status by UNAIDS6, while other states with HIV-related restrictions similar to those enforced by ROK7 are still classified as “yellow” on this map. This inconsistency in the application of UNAIDS’ assessment criteria could threaten the progress made on reducing HIV-related travel restrictions. We strongly urge UNAIDS to revoke ROK’s status as a country with no HIV-related travel restrictions until it eliminates all mandatory HIV testing policies.

Finally, we express our continued commitment to the UNAIDS goals of reducing HIV transmission, fortifying the rights of all who live with HIV/AIDS, and eliminating stigma and discrimination.

Sincerely,

Laura C. Altobelli, DrPH, MPH
Chair, International Health Section

Willi Horner-Johnson, PhD
Chair, Disability Section

Randolph D. Hubach, PhD, MPH
Chair, HIV/AIDS Section

Lea Dooley, MPH, MCHES
Chair, Population, Reproductive, and Sexual Health Section

Gabriel M. Garcia, PhD, MA, MPH
Chair, Asian Pacific Islander Caucus

Titilayo A. Okoror, PhD
Chair, Caucus on Refugee and Immigrant Health

Gabriel Galindo, DrPH, MPH, CHES
Chair, LGBT Caucus of Public Health Professionals

Benjamin Mason Meier, JD, LLM, PhD
Chair, Human Rights Forum


https://aphaih.files.wordpress.com/2017/04/apha-rok-hiv-travel-restrictions-letter.pdf

Future of Conflict Minerals murky under Trump administration

You’ve likely heard the term “blood diamonds.”  Also known as “conflict diamonds,” these precious stones have helped fund civil wars and contributed to some 3.7 million deaths in Angola, Sierra Leone, and the Democratic Republic of Congo (DRC) according to an Amnesty International report.

The term “conflict minerals” doesn’t have quite the same ring, nor a titular film starring Leonardo DiCaprio, but they are at the center of a recently leaked memo from the White House.  The memo seeks to dismantle the Conflict Minerals Rule in the 2010 Dodd-Frank Wall Street Reform and Protection Act.  Under Dodd-Frank, companies had to disclose whether or not their products contain minerals mined in the Democratic Republic of Congo or a neighboring country.  The reason to withdraw this clause that valued human life over electronics?  Perceived job loss and costs to American companies, estimated at $3-4 billion in upfront compliance costs and $200 million annually thereafter.

What is life like for the miners of conflict minerals – tin, tantalum, tungsten, and gold ore – in the Democratic Republic of Congo and neighboring countries?  The Guardian reports a systematic web of sexual violence, kidnapping, child labor, and modern-day slavery.

An overwhelming abundance of human suffering all so we can play Bejeweled on an almost dizzying array of devices.  Tech giants, Apple and Intel, have spoken out against the repeal of the Conflict Minerals Rule, but fear that enforcement will be difficult without written law.  Human rights groups representing some 100 organizations in and around DRC have also spoken out against repeal of the Rule:

Thanks to the Dodd-Frank Act, Eastern DRC has to date more than 220 certified green mining sites, more than 300 mining police officers trained and deployed to secure mining sites,an independent audit mechanism, and a regional certification system. These advances undoubtedly contribute to reducing the rate of crime and human rights violations, including rape of women and exploitation of children in mining areas. All these efforts and progress will be destroyed if the US Government decides to contradict itself by repealing the Dodd-Frank Act.

It isn’t just Big Business that has taken a hit under the Conflict Minerals Rule.  A healthy dose of criticism cites that the Rule has actually made miners and their families in DRC poorer.  In many ways, the implementation of the Rule slowed down, or stopped, mining due to implementation issues of the government and business variety.  Millions, out of work, were left between the proverbial rock and the hard place: either face starvation or join the militias that the very Rule were designed to protect them against.  Closing of mines is felt throughout communities:

With less money flowing in, shops in Luntukulu have closed. Many people struggle to feed their families through farming. “If Obama’s law wasn’t signed, the ban would not have existed,” said Waso Mutiki, 41, president of the miners’ co-operative in Luntukulu. “It destroyed everything.

Others who contest the Rule say that the it does not acknowledge or alleviate deeply systemic issues afflicting the region, such as in this open letter signed by academics, politicians, and civil society professionals:

First, while the minerals help perpetuate the conflict, they are not its cause. National and regional political struggles over power and influence as well as issues such as access to land and questions of citizenship and identity are just some of the more structural drivers of conflict. The ability to exploit and profit from minerals is often a means to finance military operations to address these issues, rather than an end in itself.

The authors of the open letter above offer some alternative strategies which seek to buoy the economy by incentivising better practice and fair competition for international and Congolese businesses. Dollar for dollar, the Democratic Republic of the Congo is one of the richest countries in the world when it comes to untapped mineral resources.  The people who seek to own that wealth and exploit its potential are many, and unfortunately, Congolese citizens and their communities are not among those to first reap those benefits.

So, what is the bottom line?   Some might say the Conflict Minerals Rule sees the forest but not the trees, doing significant damage to local economies and livelihoods despite the progress made by eliminating a driver of local conflict.  It serves as yet another example of the need for policies to be developed and refined with community feedback. A globally engaged U.S. administration might attempt to build on the successes of the Rule with foreign and trade policy that takes such feedback into account. But the current administration seems to have different priorities. Rather than approaching policymaking in a way that benefits the communities most heavily impacted, or even that takes into account the expectations of American consumers, President Trump fights for the common man…the average, American CEO:

Government and community collaboration are key in achieving meaningful reform. Whether or not the U.S. Administration will take part in that exchange remains to be seen.

Attacks on Health Care Workers in Syria and the Weakening of the International Community

Before the conflict began, Syria’s health care system was one of the most advanced in the Middle East with chronic diseases ranking as the most common health concern, vaccination coverage rates at 95%, and their pharmaceutical industry producing over 90% of the country’s medicines. Five years later, the conflict has nearly decimated the health care system and today nearly half of the country’s public hospitals and primary health care systems are closed or only partly functioning, almost two-thirds of health care workers have left the country, domestic production of medicines is down by two-thirds, and the vaccination coverage rate has dropped by half. Correspondingly, life expectancy has dropped by nearly 14 years.

Since the Syrian conflict began in 2011, Physicians for Human Rights has documented 382 attacks on 269 different medical facilities and 757 deaths of medical workers. The patterns of attacks clearly demonstrate that health care facilities and workers are being deliberately targeted. When health care workers are attacked, innocent civilians are deprived of the life-saving interventions needed for both routine and emergency care. In Aleppo alone, a health care facility is targeted every 17 hours and a health care worker every 60 hours. These alarming statistics make Aleppo one of the most dangerous places in the world to be a health care worker. APHA Executive Director Dr. Georges Benjamin noted the dire state of the Syrian health care system in a letter to the UN Security Council last December, but the situation has only worsened since then.

According to a recent report in September of this year, there were only 30 doctors serving the estimated 250,000 residents trapped in rebel-held eastern Aleppo. There are currently no more hospitals functioning at full capacity in eastern Aleppo. With the huge upswing of Syrian military activity these past few days, it is likely there are far less doctors or hospitals left. To make matters worse, humanitarian aid to eastern Aleppo has been severely restricted. Since humanitarian operations started over two years ago, the UN has conducted 420 convoys to deliver medical supplies and food to eastern Aleppo however as of late, they have not been able to make their deliveries. Health care cannot exist without health care workers, supplies, and facilities.

International humanitarian law and medical neutrality have been established to protect health care facilities and workers to ensure that they can continue to provide care during armed conflict and not be prosecuted for providing services to protesters or opposition fighters. But when health care facilities and workers are purposefully targeted and humanitarian aid is withheld, there is a clear violation of international humanitarian law that should be punished accordingly as a war crime. Though the violations in Syria are some of the most flagrant, these deliberate attacks on health care facilities and workers, used as a weapon of war, occur in many other parts of the world as well. In Yemen, over 600 health facilities have been targeted since fighting began in 2014. Médecins Sans Frontières (Doctors Without Borders) has gone so far as to call attacks on health care facilities and workers during times of war as the new normal. Additionally, health workers in Bahrain were arrested, imprisoned, tortured, and charged with crimes for caring for protesters and documenting police brutality in response to the Arab Spring uprising in 2011.

Although news outlets and humanitarian organizations worldwide have brought a lot of attention to these tragedies, bringing awareness to these atrocities is not enough to stop it. It is the responsibility of the international community to help put an end to such blatant threats to human rights. The UN’s Responsibility to Protect gives permission to the international community to intervene and protect populations when a state fails to prevent and halt genocide and mass atrocities. However, the operationalization of this doctrine has proven to be disappointing. Although most actors in the international community agree that something should be done, they have been unable to agree on exactly what must be done. No-fly zones have been suggested and temporary ceasefires have been adopted to ensure delivery of humanitarian aid but both are merely stopgap measures. These are not enough to put a stop to such unnecessary human suffering and should not be the final solution.  

As the war approaches its sixth year, the future of Aleppo looking bleak, and current estimates of the death toll in Syria surpassing 470,000, the need for for the international community to help put a permanent end to the war could not be more dire. However, given the international community’s long track record of ineffectual measures, it is unclear how they will proceed. One thing is for certain, it’s about time for the international community to ask themselves whether the decisions (or indecisions) they’ve made with Syria and other conflicts have been consistent with the principles of the Responsibility to Protect doctrine. Human lives are at stake and from a human rights standpoint, this should take precedence over any personal or state interests.