ABHINAV DESHMUKH reviews Singapore’s unique policy for foreign immigrants who are HIV positive.

Let us imagine the following scenario. You get admitted in a local hospital for a surgery. As per routine pre-operative procedure, your blood is tested for HIV/AIDS. The test results show that you are HIV positive. The shock and the emotional trauma for your immediate family would be considerable, but there is more to come. The hospital is legally required to inform the Ministry of Health of your HIV status. The long, unforgiving arm of the law comes into play and if you are a foreign immigrant, it will be a matter of time before you are deported, never to return. Your contribution to the economy, the community structures that you built in your new home, and your ability to financially support yourself all come to naught in the face of a draconian law which condemns you for a virus which does not spread through casual contact and which can be managed with modern medicine.

This is no hypothetical scenario. It is reality, and it plays out in countries like Uzbekistan, Saudi Arabia, Iraq, and Russia to name a few. It can also play out in the affluent, high HDI, first world, city-state of Singapore. Singapore’s Immigration Act currently declares any individual suffering from the Acquired Immune Deficiency Syndrome or infected with the Human Immunodeficiency Virus as a ‘prohibited immigrant’.

Singapore’s rationale for this policy is grounded in an archaic logic of ‘public health safety’. The thread of this argument runs as follows: Singapore is a magnet for immigrants from countries with a relatively high incidence of HIV/AIDS, ergo these immigrants need to be screened as they might engage in unsafe behaviour. This stand assumes that incoming immigrants will engage in irresponsible behaviour. It is also based on a premise that the primary vector of transmission of HIV is immigrants. The natural implication is that HIV is a condition foreign to Singapore, one which can be controlled simply by screening immigrants. By not applying the same standard to returning locals from the high risk regions like the Indonesian island of Batam, the selective nature of the policy makes it, at best, ineffective, if not xenophobic and counter-productive.

HIV is not an endemic condition like yellow fever nor is it a condition like SARS which is acute and spreads through casual contact. Imposing travel restrictions during outbreaks of highly contagious diseases with a short incubation period and progression is an effective control method. But in Singapore, the primary vector of transmission of HIV is sexual intercourse – a behaviour which requires consensual action from both parties. It has an incubation period that can last as long as a decade. Moreover, HIV is a pandemic and already has a footprint in Singapore. Policies which suggest otherwise are misleading and provide a false sense of security.

By legislating the mere presence of HIV/AIDS as a criterion for an action as drastic as deportation, the stigma surrounding the virus increases exponentially. This gives individuals at risk a strong incentive to go underground and avoid treatment. Denial of one’s HIV status as well as avoidance of health workers and immigration officials is a natural extension of this behaviour. In effect, the very people most in need of relevant assistance and education are cut off from the formal healthcare system.

The current treatment methodology has been shown to decrease infectivity. But currently, statistics from Singapore’s Ministry of Health show that nearly 48% of HIV cases diagnosed in Singapore are in the late stage. This means that a significant time elapses between infection and diagnosis during which time the virus may have infected others. Stigma surrounding a condition results in a delay in seeking treatment that can potentially reduce the risk of transmission of the virus. Singapore’s current immigration policy towards immigrants with HIV feeds into this stigma. A policy which incentivises delay in critical treatment is not only ineffective, it is counterproductive.

Dr Amy Khor – Singapore’s acting Chairman of the National HIV/AIDS Committee – has also been quoted publicly drawing a parallel between Singapore’s immigration policy and that of other first world countries like Canada and Australia. Dr Khor’s comparison is incorrect. Canada does not view people with HIV/AIDS as a threat to public health. While Canada does consider whether the prospective immigrant may place an ‘excessive demand’ on the publicly funded healthcare system, this applies to anyone with a medical condition that may place demands on the welfare system and not just people with HIV/AIDS in particular. Australia too has recently taken a more pragmatic approach and is easing restrictions on HIV/AIDS to meet skill shortages.

Singapore may do well to take a leaf out of Iceland’s approach to immigrants with HIV/AIDS. Iceland requires an HIV test to be undertaken when applying for permanent residency, but for a very different reason. If you happen to be HIV positive, then on getting permanent residency you are immediately enrolled into the national healthcare service and the standard six month residency requirement is waived. The first step towards addressing HIV is managing the stigma associated with it, and current policy in Singapore does not address the same.

Singapore is often criticised by organisations like Amnesty International for its poor human rights record. Discriminating against individuals solely on grounds of a health condition which is not highly contagious, which will not pose an additional burden on the state exchequer and where the viral pool already exists in the country is fair ground for a charge of violation for human rights.

It is not that Singapore is unaware that the battle against AIDS cannot be won unless they address the stigma associated with the condition. In fact the late Dr Balaji – then Senior Minister of State for Singapore’s Ministry of Health – opined as much on the floor of the UN General Assembly when he acknowledged that Singapore’s control measures would not work unless the citizenry engaged in “frank, open discussions about the disease and sexual behaviour”. He assured the chairman of the General Assembly that Singapore was working “actively towards reducing stigma and discrimination through education of our community”: a laudable view which would do well if it were implemented on the ground.

It is indeed Singapore’s right as a sovereign state to choose who may or may not enter its borders. But grounds for visa denial need to be founded on firm evidence that the prospective immigrant is of no asset to Singapore. To impose a blanket restriction on the entry of people with HIV/AIDS even for short-term stays is baseless paranoia reminiscent of a bygone era where discrimination was rife.

The United States of America removed AIDS related entry restrictions in 2009 with President Obama opining that they were “rooted in fear rather than fact”. China followed suit in 2010 proclaiming that the travel ban was grounded in “limited knowledge of HIV” and was proving to be “inconvenient” for China. As recently as March 14th this year, Tajikistan lifted all entry restrictions on the residence of people with HIV. Maybe it is time Singapore evaluate the effectiveness of its current immigration policy; after all, there is a far more crucial battle to be lost by swimming against this tide.

Abhinav is a recent graduate from the National University of Singapore. This is a modified version of coursework compiled for the module From Microbes to Nations: The Case of HIV/AIDS.

 

Posted by Alice Dawkins

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