Wednesday, December 16, 2009

Discuss: What is an acceptable HIV testing policy for foreign nationals?

The requirements that E2 visaholders be subject to one-time or annual HIV tests has been a great source of controversy this year. Anti-English Spectrum pushing for this has made the policy seem rooted in xenophobia, even though public health officials in South Korea have pushed for such regulations even before AES ever existed.

HIV testing is caught between public health concerns and human rights concerns. The government and health authorities have a role to protect the public from the spread of dangerous or deadly diseases, especially when they end up footing the bill for costly treatment, but mandatory testing can be seen as an invasion of privacy or even stigmatization. When it seems to be directed only at certain groups, which may be the case with testing foreign

So that's my question: What is an acceptable HIV testing policy for South Korea vis-à-vis foreign nationals?


Consider the following questions:
  • If most but not all ROK citizens, through their jobs and the National Health Insurance Corporation, military service, blood donation, etc., are routinely tested for HIV, is it acceptable to require the same of all seekers of E2 visas? 
  • If ROK citizens are typically tested for HIV only once (say, during military conscription or when they first enter a corporation), is it acceptable to require foreign residents to be tested repeatedly when their visa comes up for renewal? 
  • What if most ROK citizens are not tested at all? Is it still acceptable to require some or all foreign nationals to be tested upon entering the country with a new visa?
  • Is it acceptable to test only some foreigners, like just teachers (i.e., E2s, E1s, and any F2, F4, or F5 who teaches children) or just those with teaching-specific visas (i.e., E2 or E1) or just those who might teach children?
  • If E2s and E1s should not be tested, then what about E6 visaholders (i.e., those on "entertainment visas" who are often knowing employees for Korea's de facto legal sex industry? (That many of the women who come to Korea on E6 visas are duped into the sex trade is not something I wish to ignore, but if possible, I wish to treat that as a separate issue.)
Separate from the fairness issues above, should we look at this completely as a privacy issue? Specifically:
  • Is the problem with testing for E2 visaholders one not of fairness at all but one of privacy? In other words, would any mandatory testing policy be unacceptable, even if every ROK national in South Korea were subject to HIV testing? 
  • Should ROK nationals be subject to regular HIV testing or is it too stigmatizing?
  • Does a blanket requirement remove stigma or increase it? Do public health concerns trump this?
  • If mandatory HIV screening is a stigmatizing and therefore should not be done, does this apply to other diseases, like tuberculosis or syphilis? What, if anything, makes HIV different?
    I'm genuinely curious what others think about this. I think a sincere discussion about some of these questions might be a way to reach a consensus about an acceptable policy.

    I'll be up front, however, that one of my biggest concerns is that we've let a heightened sense of so-called "human rights" trump good health care planning. Yes, getting HIV tested may be unpleasant and even humiliating, but not nearly as much as getting HIV. South Korea has — so far — largely kept HIV at bay, but it's not necessarily clear what factors or policies have led South Korea to that point. Would a purely "human rights"-oriented approach dismantle the dikes and bulwarks, or would they just remove archaic practices that are designed to make the public feel good but are inefficacious or even detrimental?

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    18 comments:

    1. i'm against hiv testing because i faint at the sight of needles. for real.

      however, in the interest of public health and safety, i think it's a sacrifice that has to be made and not a human rights issue at all. i do think the thing where you get tested in your home country and then again once you arrive in korea is excessive, though.

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    2. Perhaps another question to ask would be has Korea really "largely kept HIV at bay" or is the policy of testing only specific groups keeping the numbers low?

      I refused the repeat testing & lost my job. While talking to Korean friends/co-workers about the policy, I found they were alarmingly ignorant of how HIV is both prevented & transmitted. My biggest concern with the policies of the KIS & the regional Education Offices is that they give the impression that HIV is a 'foreigner' problem and, thus, Koreans don't need to worry about being educated on the issue or getting tested. That really doesn't have anything to do with human rights.

      I don't think compulsory testing for HIV is acceptable (I'm on the fence for sex workers) when you deport, shun or otherwise stigmatize if a person returns a positive result. I would prefer to see more confidential, voluntary testing going on. Of course that would mean heaps of education and changing attitudes about HIV/AIDS, which I think is improbable while these policies are in place.

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    3. HIV isn't exactly something you can hide. Untreated HIV will develop into AIDS after a decade, so unless things have changed drastically in the last decade, presumably those people who have AIDS are identified as having AIDS, even if they were never tested for HIV. Kushibo, I'm sure you with your background can correct me here.

      Dancing Bear, I don't think Korea's all that unique (or unjustified) in demanding that immigrants not have HIV. I wouldn't want people with serious communicable illnesses immigrating to my country either. That said, what boggles my mind is that foreign nationals with full-blown AIDS are welcome to come and stay indefinitely as long as one parent is Korean, with the presumable result (to Koreans) of taxing medical resources and infecting others.

      In that sense, Korea is out of touch with places like Canada, which I presume doesn't waive its requirement for an HIV test immigrants if one parent was once (but is no longer) a Canadian citizen. The perception of AIDS then does seem to be that of a disease of whites, blacks, browns and other non-ethnic Koreans.

      Repeat testing is also ridiculous, I agree. We don't test immigrants for AIDS every year.

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    4. What ever tests that are implemented against foreigners should be conducted outside of the country before the visa is given.

      Anything required after that should be the same as anybody else residing in Korea, so as not to infringe the country's own constitution.

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    5. Instead of just soliciting for opinion on what is a health issue, why not ask Korean health care professionals?

      Please see the joint 2009 study on this very issue released by the Division of AIDS, Center for Immunology and Pathology, Korea National Institute of Health, Korea Centers for Disease Control and Prevention AND the Division of Epidemic Intelligence Service, Korea Centers for Disease Control and Prevention.

      The conclusion of the report reads:

      "Conclusion: A question on the efficiency of current mandatory test is raised because the seroprevalence of mandatory test takers was low. However, HIV ISG included voluntary test takers was high in our result. Therefore, we suggest that Korea needs to develop a method encouraging more people to take voluntary tests at PHCs, also to expand the anonymous testing centers and Voluntary Counselling and Testing Program (VCT) for general population to easily access to HIV testing."

      Read it yourself:
      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689198/

      I personally met with several researchers in this group and asked, "is there any better way to fight AIDS in Korea?"

      All said no, except one researcher who explained, "well, it wouldn't be popular politically and wouldn't make sense economically because of the low rate of infection in Korea, but scientifically the best way would be to give mandatory HIV tests to everyone in the whole country (Korean & foreigner) under an anonymous privacy protected system that wouldn't record data on individuals or deport them but would provide counseling and treatment. I believe Bill Clinton suggested something similar for Africa." Others agreed that this may be a good approach for some countries where the rates were high but not for Korea.

      Next, you could ask Korean legal experts what they think would be the proper policy.

      For example, Judge Yu who canceled the deportation order of an HIV+ foreigner in the Heo case:

      "From the perspective of HIV/AIDS prevention, the most dangerous thing for society is not persons who are infected with HIV and aware of their status, but persons who are infected with the disease and unaware of their status. A person who is aware of infection will be less likely spread the disease. On the other hand, a person who is unaware of infection is more likely to spread the disease. In the final analysis, encouraging the public to voluntarily receive HIV testing by protecting the human rights of people living with HIV/AIDS is the most effective policy for preventing the spread of the disease. The current policy of deportation, therefore, is not a sound method for protecting the public health."

      You could also listen Korean Human Rights groups

      "Human right groups have requested the government to abolish the AIDS Prevention Act and to enact the HIV/AIDS Victims Human Rights Act in 2006. This proposed Act would prohibit HIV testing without proper consent, punish offenders of discrimination and those who disclose the identity of those living with HIV/AIDS, and require firms, schools, and medical professionals to have human rights education."

      http://iise.pitt.edu/publications/ncontents/v9/n2/ise200808.pdf

      @ Adeel
      I wouldn't want people with serious communicable illnesses immigrating to my country either.

      But HIV/AIDS isn't a "serious communicable illness" Adeel. In fact, under Korean law it ranks the least contagious of all contagious diseases. There are 3 tiers and AIDS is third behind a whole host of more contagious diseases that are not screened for.

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    6. I appreciate your comments, Mr Wagner. I'm a little busy to answer them or the others' right this moment, but I wanted to thank you for providing that lengthy but informative comment in the spirit of discussion.

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    7. I don't think Korea's all that unique (or unjustified) in demanding that immigrants not have HIV.

      Korea's HIV policy towards foreigners is "unique" in that it is among the most restrictive in world.

      Read the UNAIDS 2009 report for yourself here:
      http://data.unaids.org/pub/Report/2009/jc1727_mapping_en.pdf

      I tried to discuss the policy here:
      http://www.koreaherald.co.kr/NEWKHSITE/data/html_dir/2009/12/07/200912070091.asp

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    8. Thanks Kushibo, nice to be appreciated.

      But please bear in mind that strictly speaking these are not "my" comments. They are extended quotes from Korean experts.

      I think it should be understood that what I am doing (have been doing) is advocating a Korean position that has not received enough attention.

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    9. B_Wagner, thanks for the corrections. An E2 visa does not allow a long-term stay, but I think (and, again, am more than willing to be corrected here) there are very few countries that consider someone with HIV to be a desirable immigrant. Korea deporting foreigners once their status is disclosed is really not that different from denying entry for being HIV positive in the first place.

      I agree most of all with your first comment. I think professional, qualified opinions are more valuable than those of philosophy majors like myself.

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    10. Ben Wagner wrote:
      But please bear in mind that strictly speaking these are not "my" comments. They are extended quotes from Korean experts.

      But you still did the homework. That alone is a lot.

      ReplyDelete
    11. there are very few countries that consider someone with HIV to be a desirable immigrant.

      First, let's be sure to distinguish immigrants from non-immigrants. The E-2 visa is a non-immigrant visa. Immigrants intend to stay permanently.

      As for what constitutes a a 'desirable' immigrant (or non-immigrant for that matter) it depends on what motivates the State.

      Clearly States, like people, are motivated by purely practical considerations such as money, talent, power, prestige, etc. - bottom line type considerations - but States, like people, are also motivated by other considerations. For example, issues of identity, reputation,'doing the right thing', etc. It's important not to underestimate such factors.

      Under either analysis it's easy enough to come up with several scenarios where an individual living with HIV could indeed be a very "desirable" immigrant or non-immigrant.

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    12. The issue that I have with it is that only E-2 visa holders are required to have the test done specifically for a visa. F-series visa holders are not.

      If Korea wants to test foreign teachers, they should be testing all. Not a select few with different DNA.

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    13. Well, mandatory testing is not the same as routine testing.
      In several Western countries pregnant women, rape victims and prostitutes are all routinely tested but it is not mandatory, and there are good reasons for each.
      telling someone that they have to be tested and that if they 'fail' they will be deported is a lot different to saying 'we think you should have a test for this this and this reason, how about next wednesday?' The reasons for testing teachers (and not bankers) are not very good.
      In fact, its this issue that creates and fuels the stigma - against both foreign teachers and HIV/AIDS. Routine testing does not create a stigma, but mandatory testing, associated with losing one's job does - it says that people with HIV are not fit to teach. It also suggests not only that E2 teachers are more likely to have AIDS, but also that they are paedophiles, since that is the only situation in which it is relevant.
      Of course it's possible that such transmission could occur, but it's a waste of resources to carry out the current action, since its easy to avoid testing (by teaching illegally) and highly unlikely. I would say that most of all it's not worth the stigma it creates.
      This is separate to the human rights issue. The rights to dignity and freedom of descrimination for example, are not in place for reasons of disease prevention. They might be the reason people object so strongly, however.I suspect if testing was done in a proper manner, and offered routinely but was not obligatory, the vast majority of teachers would take it. IMHO they object because of the rights, the fact that their actions might actually produce other positive consequences is an added bonus

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    14. I suspect if testing was done in a proper manner, and offered routinely but was not obligatory, the vast majority of teachers would take it.

      You are 100% correct and there is no need for speculation on this one. We have the data.

      English teachers were offered testing in a proper manner, it wasn't obligatory and just as you suspected, a huge number of them came in for voluntary testing. It was working just as it was designed to.

      Until Anti-English Spectrum put a stop it...

      It was these high voluntary testing rates that were cited as evidence that English teachers were HIV carriers and led an immoral lifestyle. Who else would even consider being tested for AIDS? The AES group petitioned the Ministry of Justice citing the fake article they had helped to create.

      Of course now there is less voluntary testing by foreigners and Koreans because of the stigma this mandatory testing regime and the foreign teacher AIDS scare has helped to amp up, and this is bad for the fight against AIDS. But public health be damned, the mission was to stigmatize foreign English teachers and this has been accomplished.

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    15. [Link above is broken, this works.]

      You are 100% correct and there is no need for speculation on this one. We have the data.

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    16. Hey there,

      For my two cents, I don't have a problem with HIV testing, or all the other health testing for that matter, as part of the visa process. I hadn't been very vigilant about my health and being checked for things in the past, so now I know I am healthy. Or do I? I was in-country after the policy was instituted. I went with my boss to have my testing done. I covered my eyes one at a time and read off the sight chart. Okay. Well I have glasses, so I know my eyesight isn't perfect. I could even have told them what my eye prescription is. I had my height taken and my weight. I don't remember a blood pressure reading being done (but don't hold me to that). After all those preliminaries, I went with my boss down to the fluids gathering and testing area. They handed me a cup and I headed into the bathroom where I was in the company of around ten or twelve other people filling cups also. There was not even a cover on the cup. They stuck me and took my blood and labeled it, better than they labeled my piss, I might add. And I had my chest x-ray. No radiation protection for the jewels, or any other part of me. All righty, then. The final part of the testing was the dentistry check. We went next door to the dentist office and I sat in a chair and the "dentist," for I am not convinced she was a dentist, told me to open my mouth. She took a quick look in my mouth. It seemed to me that she was simply assuring herself that I did indeed have most and possibly all of my teeth. She didn't use any dentist instruments to assure herself of the quality of my teeth or anything more than that they were there. And that was that. My comprehensive health check. A week or so later, I found out I will live. From my boss, who got the results of the tests, but didn't bother to give me the paper to read for myself (not that I could, for it was all in Korean), let alone open for myself, being what I consider confidential information. Oh, and she told me how I had had pneumonia in the past because the doctors at the hospital had phoned her to tell about my past medical history as revealed by my x-rays and other tests. And I can only assume that HIV tests were part of that whole process, since they took the blood, and part of the whole business that made it a mandatory requirement.

      Given the "standards" that were evident in that round of health tests, mostly by the conspicuousness of their absence, I have no confidence in the health testing procedures for visa purposes. And I have no regard, absolutely no regard, for that hospital, given they made absolutely no attempt to maintain the confidentiality of my health information, or indeed to communicate it to me in any way, much less in a way that I could understand it. I won't go so far as to say the whole process is a sham for some sort of public relations purpose, because when I had to repeat the process in order to renew my visa a year later, I had a much more confidence-inspiring experience at another hospital. But there are certainly hospitals that don't put much attention into the health check, and presumably HIV testing, process.

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    17. And to finish, what if I had come up positive on something, HIV/AIDS in particular, since that is the focus of this post. True, at some point, it would become obvious I suppose. But it is still my information and it should be my decision how to expose it to the sources that require the information. It shouldn't be up to the doctors who can indiscriminately let my boss know my results. If I had something that needed to be addressed, I want to be the first to know, not the last. And, quite frankly, if I did come up positive for something that required treatment, I damn well wouldn't be staying here. I would be going home where I could be almost completely assured of having a doctor that could talk to me and discuss treatment options and get on the road to recovery. Or whatever. I have had several interactions with the medical system here and too often I find that the doctors just do things for what they find without ever explaining what they are doing, what medications I am being given, what treatments are being enacted. I care what goes into my body. And what is taken out of it. I don't know if Koreans who interact with the system just don't care or have been conditioned, through dictatorships and conquerors in the past, not to question what sort of treatment they are receiving. All Koreans can't be like that. There have to be at least some, if not lots, who question what people are telling them and doing to them. But wherever they are, the system still has this great big flaw. And if that were fixed, I think also many more people would have less of a problem with the health check.

      Sorry for the length of this and the side issue of health check in general. It seemed relevant to my point.

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    18. And one other thing. You made reference to Korea having a much smaller AIDS population than other places, if I read your post correctly.

      I don't think that conclusion is merited. The known population may be small, but how many are either secret, or worse, unknown? Given the stigma attached to HIV/AIDS in this country that I perceive through the blogs that I read, it seems there must be a large degree of fear for anyone even suspecting they are HIV positive in this country. I don't know if it is true or not, I don't know anyone who would know. But if people are afraid of even thinking that they might be, and of what would happen to them and how they would be treated if it were true and known, there seems to be a low incentive to act on the nebulous possibility and get tested to find out for sure. I don't think you can reasonably suggest that Korea has been successful at keeping HIV/AIDS a small problem.

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