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

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More HIV discrimination from the ROK government: Korea disqualifies students with HIV from receiving scholarships

A few regular readers might be familiar with the Korean government’s ongoing misrepresentation of its HIV-related immigration restrictions: while it continues to receive undeserved recognition from the UN for being a country free of HIV-related travel restrictions, it mandates HIV tests for native-speaking English teachers, EPS workers (manual laborers), and entertainment workers. Despite claims from KCDC and Korea’s ministry of foreign affairs that immigration restrictions have been lifted, one English teacher won a discrimination case with the UN CERD earlier this year, and another case is pending with the ICCPR. Our Section was even successful in pushing through a resolution on immigration restrictions tied to HIV status at this year’s APHA Annual Meeting that called Korea out specifically for its double-talk.

Now there more evidence of discrimination to add to the list. The Korean Government Scholarship Program, which provides funding and airfare for non-Koreans interested in pursuing post-graduate degrees at a Korean university, is open to a small number of foreign nationals each year and is actively advertised on Korean embassy websites and even featured on several university websites for current undergraduates who might be interested. The program “is designed to provide higher education in Korea for international students, with the aim of promoting international exchange in education, as well as mutual friendship amongst the participating countries,” and the payment includes tuition, airfare, a monthly allowance, a research allowance, relocation (settlement) allowance, a language training fee, dissertation printing costs, and medical insurance. Which sounds lovely, except:

Applicants must submit the Personal Medical Assessment (included in the application form) when he/she apply for this program, and when it’s orientation, an Official Medical Examination will be done by NIIED. A serious illness (For example, HIV, Drug, etc) will be the main cause of disqualification from the scholarship.

It is also worth noting that pregnancy can disqualify candidates as well.

The best part is that this information is not even hidden: a Google search on the above line pulls up dozens of results, and the restrictions on prominently featured on the websites of Korean embassies to the US, the UK, Australia, Malaysia, plus the Korean Education Center in New York, GWU’s Sigur Center for Asian Studies, and even Seoul National University (DOC), the most prestigious university in the country.

It’s (UN) official: South Korea’s mandatory HIV testing for foreigners is racial discrimination

Note: This was cross-posted to my own blog.


South Korea has come under fire in recent years for its treatment of immigrants, migrant workers, and non-ethnic Koreans (and even their own working-class people). Last fall, Bitter Harvest, Amnesty International’s report on the country’s treatment of agricultural migrant laborers highlighted how Southeast Asian migrants went unpaid, were subjected to harsh treatment and squalid living conditions, and were either deprived of medical care or forced to pay for their own care out of pocket (from their own meager wages). In some cases, the migrants were forced to take (and pay for) an HIV test, with employers requiring a negative test result.

In the case of migrant workers, this is clearly illegal – currently, the only visa category for which the South Korean government requires an HIV test is E-2 (native-speaking English teachers from the US, Canada, the UK, Ireland, South Africa, Australia, and New Zealand). However, even this requirement – first implemented in 2007 in response to a racially-fueled moral panic – has been determined to be discriminatory and racially motivated, according to a ruling from the UN’s Committee to End all forms of Racial Discrimination (CERD) handed down last week. The ruling, issued in response to a case filed by a New Zealand woman who lost her job in 2009 after refusing to take an HIV test to renew her contract – has been long awaited by the expat ESL community in Korea. Whether the Korean government will remove the requirement remains to be seen.

The case was brought to CERD by Benjamin Wagner, an international human rights attorney who co-authored a legal paper on the issue of South Korea’s use of HIV testing as a proxy for racial discrimination with Matt van Volkenburg. The paper (PDF) provides an excellent background on the history, political and cultural climate, and xenophobic advocacy efforts that led to the implementation of the testing requirement, as well as how the requirement is a clear example of South Korea shirking its international human rights obligations:

The HIV and drug test requirements for foreign teachers were first established as emergency measures in 2007 by the Ministry of Justice
(“MOJ”), which claimed they were necessary in order to “ease the anxiety of the citizens.” Part II of this Article examines the background and
context of the implementation of these requirements and argues that they were introduced during a period of media hysteria and moral panic…a civil society group called the “Citizens’ Group for Upright English Education”…succeeded in courting public opinion against foreign English teachers by contributing to highly sensationalized media reportage replete with lurid tales of perversion, sex crimes, drug use and AIDS. This group was also successfully able to influence national policy by petitioning the government for measures against foreign teachers, including mandatory HIV and drug tests.

Part III examines the ROK’s international commitments to eliminate discrimination and stigma based on actual or presumed HIV status and
examines how and why the ROK has failed to honor these commitments.

Korea’s HIV restrictions for foreign teachers are among the most extreme form of HIV restrictions in the world…Of the forty-nine countries in the world that continue to have some form of HIV-related restrictions in place for foreigners only about six have restrictions so extreme as requiring in-country testing for foreign workers that must be repeated on a regular basis, and nowhere are teachers subject to such restrictions. Indeed, the ROK’s extreme position toward its foreign teacher population has attracted the attention of UN Secretary-General Ban Ki-moon who has urged the ROK to eliminate its HIV restrictions on foreign teachers.

Obviously, any foreigner who tests positive for HIV is immediately detained and deported; in 2008, the Korean CDC reported that it had deported 521 out of 647 HIV-positive foreigners. Non-nationals of Korean ethnicity have been able to successfully challenge such deportations, but the Korean judicial system explicitly differentiates between the legal rights of citizens versus foreign nationals.

Interestingly, South Korea has given CERD “the same authority as domestic law” regarding foreign nationals; however, this means next to nothing as Wagner explained in a different piece last week:

Professor Kyong-Whan Ahn…remarked that the constitutional analysis used by Korean courts to determine whether an incidence of discrimination has occurred is relatively underdeveloped. The method relied upon by courts is the “reasonableness test”. But, Ahn complains, decisions are all too often “a foregone conclusion” with little analysis or scrutiny.

[T]he status of the CERD is unique in that “it has the same authority of domestic law and does not necessitate additional legislation,” as the Republic of Korea has made clear to the Committee on several occasions. Nevertheless, the Committee has responded, “although the Convention forms part of the domestic law and is directly applicable in the courts of [South Korea], there are no court decisions which contain references to or confirm the direct applicability of its provisions.” The Committee has pointed out to the government that the situation may be the result of “a lack of awareness of the availability of legal remedies” and has recommended “information campaigns and education programmes on the Convention and its provisions.” Unfortunately, however, the treaty remains relatively unknown in Korea and neither the government nor the courts have done enough to change that.

van Volkenburg, who has been covering this issue (and its origins) since it all began in 2005 at the long-running Korean expat blog Gusts of Popular Feeling, has a great summary of the ruling and its implications (as well as the best collection of links to the news coverage of the ruling):

The summary makes public the justification the UMOE offered for the tests – something that many people taking these tests have known for years, but never admitted by the government:
[D]uring arbitration proceedings, L.G.’s employers, the Ulsan Metropolitan Office of Education (UMOE), said that HIV/AIDS tests were viewed as a means to check the values and morality of foreign English teachers.

One of the Committee’s recommendations isn’t very surprising:

The Committee recommends that the State party grant the petitioner adequate compensation for the moral and material damages caused by the above-mentioned violations of the Convention, including compensation for the lost wages during the one year she was prevented from working.

It continues with much more sweeping recommendations, however:

It also recommends that the State Party takes the appropriate means to review regulations and policies enacted at the State or local level related to employment of foreigners and abolish, both in law and practice, any piece of legislation, regulation, policy or measure which has the effect of creating or perpetuating racial discrimination. The Committee recommends the State party to counter any manifestations of xenophobia, through stereotyping or stigmatizing, of foreigners by public officials, the media and the public at large, including, as appropriate, public campaigns, official statements and codes of conduct for politicians and the media. The State party is also requested to give wide publicity to the Committee’s Opinion, including among prosecutors and judicial bodies, and to translate it into the official language of the State party.

This doesn’t just refer to English teachers, but to regulations for all foreign workers. And as I’ve covered here, the references to the conduct of the media and politicians is very pertinent, considering the ‘Citizens Group for Upright English Education’ (also known as Anti English Spectrum) worked closely with the media and had access to politicians when pushing for the creation of the HIV testing policy (among others) in the first place.

It will be interesting to see how the Korean government will respond to the CERD’s ruling – whether it will in fact change the law in accordance with its treaty obligations. Based on South Korea’s history of human rights protections, it does not look promising. Even when human rights principles are codified into law, employers (and often police officers) who violate workers’ legal rights do so with widespread impunity and are rarely prosecuted or held accountable – as demonstrated by the cases of the migrant workers in Bitter Harvest and the workers enslaved on salt farms on the islands of Jeollanam-do. The admission that HIV tests were seen as a way to “check the values and morality” of visa applicants is a slap in the face – doubly so considering that only foreigners are required to have “upright values” in order to get jobs.

Nonetheless, the CERD ruling is a major victory – a solid foundation on which to pressure the South Korean government, which has demonstrated that it wants to be taken seriously in the international community.

Perspective: A Day in the Life of Another Country’s Healthcare System

I will be the first one to admit that my job teaching English to privileged Korean children at a private academy has almost nothing to do with public health. While I have maintained most of my international-health related activities (and even added some new ones since being here), my income-generating activities are not typically health-related. There are times, however – and more than I originally expected, to be sure – when my public health knowledge and training comes in handy. For example, we have a lot of debate classes, and obesity, fast food, and eating disorders are frequent topics. It can be really enriching to bring my professional training into the classroom and engage my students beyond the textbook.

And then I occasionally get responses to writing assignments like these.
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If your first instinct is that this is just a witty response from a smart-ass middle school student, think again. I got two more with the same response.

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Teacher, what?

By and large, South Korea’s healthcare system comes very highly reviewed. The government provides universal health coverage through the compulsory National Health Insurance scheme, which covers basic services – half of the premium is paid by the individual and the other half by that person’s employer. Experts and pundits love to list it as one of the examples that America’s own expensive and oh-so-broken system should aspire to be, as South Korea only spends about 7% of its GDP on health care (compared to our whopping 17%). Koreans, of course, take great pride in their healthcare system. A prime example can be found on the popular blog Ask a Korean, where the author writes about this very same topic.

Part of the reason why the Korean did not follow the [American healthcare debate] was because the entire thing was so moronic: to the Korean, it is obvious that a country should guarantee its citizens a health insurance, and the cheapest way to achieve that is a single-payer system like Korea’s. Scores of advanced and semi-advanced countries in the world manage to do this without turning their country into Russia. (Unless, of course, if their country is Russia.) There is no point in watching a debate where the other side is arguing the sky isn’t blue.

What has been strange for us to understand was not Koreans’ views on healthcare, but on accessing it. We noticed very early on that our Korean coworkers go to the hospital for everything – and by that, I mean everything. Have a stomachache? Time to go to the hospital. Sore throat? Going to the hospital. Cold? Hospital. Fever? Flu? Twitch under your eye? You get the idea. During our first few weeks, I was always very concerned to hear that someone had gone to the hospital, but now I don’t even bat an eye.

Coming from a country where healthcare is so expensive that people wait until they are at death’s door to get treated (and then, by necessity, have to go to the hospital), I found a system with the opposite problem to be somewhat fascinating. I asked one of my friends here, who is a neurologist at a local hospital, about it, and he explained some of the reasons behind this tendency:

  1. Many Koreans think that bigger is better, which means if they go to a hospital for a simple cold, they feel like they get better service than they would get from a small clinic.
  2. Also, many Koreans feel that they need to see someone who works at a reputable facility, graduated from a prestigious university, or has multiple advanced degrees to be satisfied, even for minor ailments.
  3. Third, he explained, Korea is still a hierarchical society, which means that upper-class individuals go to upscale hospitals for treatment to get the medical treatment they feel that they deserve according to your socioeconomic status.

In a system where a procedure costs the same amount no matter where you go, these reasons make sense, particularly in a culture that is as socially competitive as this one. Of course, every healthcare system has its own issues, and Korea is no exception. Because the price for a given procedure is the same everywhere and, as a result, larger hospitals have people lined up out the door to get their runny noses looked at, providers are pressured to see as many patients as possible in the shortest amount of time to minimize wait time and maximize profit. Absolutely everyone knows that this is a terrible idea, leading to stories like the one I read in the local English-language paper about a small colonoscopy clinic in Seoul that was seeing hundreds of patients per day – and not properly cleaning their instruments because they were so rushed. Also, much like the U.S., Korea is starting to see its healthcare costs rise and must come up with a way to continue to finance them, lest they become sustainable. Still, as Americans prepare themselves for the upcoming changes that the landmark healthcare reform will bring over the next few years, it is interesting to put the uproar into perspective.

Not all of the write-up books that I received were so drastic in their responses to the runny nose question. Two of my best students also gave me slightly more sensible answers.

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Global Health News Last Week

POLICY

RESEARCH

  • A paper published in Science by a research group at the University of Maryland demonstrates that a fungus, Metarhizium anisopliae, can be used to combat the malarial parasite inside the mosquito. Another promising study suggests that a compound produced by a seaweed in Fiji could be used to combat malaria.
  • A new study has shown that that Internet kiosks providing information on prenatal and postnatal care have helped reduce infant, child, and maternal mortality rates in rural India.
  • A study published by the Harvard School of Public Health last year found that the poorest third of the world’s population account for only 4% of surgeries worldwide, and that over two million people in low-income countries have no access to life-saving surgery.
  • The first phase trials of the HIV vaccine developed in India were completed with no side effects reported. Meanwhile, a three-year research trial on a vaginal anti-HIV gel has been launched in Rwanda.
  • The Trachoma Atlas, an open-access resource on the geographical distribution of trachoma, was launched by a team of collaborators from the London School of Hygiene & Tropical Medicine, the International Trachoma Initiative at The Task Force for Global Health, and the Carter Center. It is funded by a generous donation from (you guessed it!) the Bill & Melinda Gates Foundation.
  • The European Solutions Enterprise for Neglected Diseases (euSEND), a new initiative, based in the Netherlands, was launched to aid in the fight against neglected tropical diseases. The organization’s goal is to “take the role of matchmaker” to facilitate partnerships in research for NTD treatments and vaccines.

PROGRAMS

  • Swaziland has a large-scale circumcision drive in an attempt to lower HIV rates.
  • Cash-transfer programs as a means of assisting the poor are beginning to gain attention and popularity from development and economic professionals. Mexico’s and Brazil’s have captured particular attention and are credited with poverty reduction and GDP growth.
  • The first methadone maintenance program in sub-Saharan Africa recently opened in a hospital in Dar es Salaam, Tanzania. Heroin use is a growing problem in port cities, where the drug passes through en route from Afghanistan to Europe.

DISEASES