Chapter 7 Mandatory HIV Screening Policy and Everyday Life A Look Inside the Canadian Immigration Medical Examination

Laura Bisaillon

Story and science are interrelated, interactive, and ultimately constitute each other. . . . The natural world and the cultural worlds share the burden of creating disease realities.1

I had grasped well that there are situations in life where our body is our entire self and our fate. I was in my body and nothing else. . . . My body and nothing else. . . . My body . . . was my calamity. My body . . . was my physical and metaphysical dignity.2

In this chapter, I report findings from research using institutional ethnography (IE) that illuminate the practices associated with the mandatory HIV (human immunodeficiency virus) screening of people who are refugee and immigrant applicants to Canada. I focus on interactions between immigrant and refugee applicants who live with HIV and federal government–appointed immigration doctors during the official immigration medical examination. What are the everyday activities of persons living with HIV? What happens during the medical examination? How are the visits socially organized, and what happens there?

I advance two arguments. First, there is relevance and practical value in investigating public policy from within people’s concerns and the material circumstances of their everyday lives. Such empirical accounts circumvent speculative, abstract, and ideological knowledge and understandings about the side effects of policy. Second, the mandatory HIV testing policy and the medical, legal, and bureaucratic practices associated with it give rise to serious and significant challenges in the lives of HIV-positive immigrant and refugee applicants, and these must be understood as socially produced and set within the broader socio-political contexts in which they occur. Until my research on HIV-related practices in the Canadian immigration medical program, what exactly was happening to people during the medical examination had not been the focus of sustained ethnographic inquiry—in part, I argue, because whatever practices go on there are taken for granted as being among the activities that “just must happen” to people who hope to settle and stay in Canada permanently.3

After reading this chapter, the reader will be able to see and appreciate the considerable effort and time-consuming work that people do during their immigration application process. Analysis of the social organization of the medical examination within the broader process of immigrating when one lives with HIV reveals the distinctively prejudicial treatment of people with HIV within the Canadian immigration system.

Context of Mandatory HIV Screening of Immigrants

Since 2002, Canada has required HIV testing of all persons aged fifteen years and above who request Canadian permanent resident status (such as immigrant and refugee persons) and temporary resident status (such as migrant workers, students, and long-term visitors from certain countries), with some exceptions. The federal immigration department manages the testing program and contracts physicians to practice what I named “immigration medicine,” which involves arranging for HIV testing and preparing a medical file (Bisaillon 2013, e45). There are an estimated 2,900 immigration doctors and radiologists worldwide carrying out medical examinations and interpreting chest X-rays as state contractors; approximately 925,000 examinations were conducted in 2019 (CIC 2021). Citizenship and Immigration Canada’s Global Case Management System reveals the pattern of steadily increasing numbers of yearly immigration medical examinations over time (Imrie 2019). Tuberculosis, syphilis, and HIV are the three health conditions for which mandatory screening is required (Canadian HIV/AIDS Legal Network 2009; CIC 2002).

The rationale for Canada’s mandatory HIV testing policy is not clearly articulated, and it remains unclear why the HIV test was singled out as the only addition to the medical examination in recent history. Before 2002, there was no blanket immigration screening for HIV. I have previously addressed key human rights consequences of the mandatory HIV screening policy. I argued that there are sound options for responding to human rights challenges the policy posed and formulated actionable recommendations for change (Bisaillon 2010). As expressed by Dvora Yanow (2000, v), “The promise and implications of a policy are not transparent and easily evident in its text. . . . The ‘architecture of meaning’ of a policy is revealed by the systematic investigation of policy categories and labels, metaphors and narratives, programs, and institutional places.” As with all public policy, Canada’s mandatory HIV testing policy is neither value neutral nor without intended effect.

The number of HIV-positive applicants admitted to Canada is very small relative to the population increase through immigration and the number of people living with HIV who live in Canada. Between 2002 and 2010, for example, 4,374 persons were reported to have tested HIV positive during their immigration medical examination. In 2019, immigration department medical officers found 1,400 people inadmissible on health grounds based on determination of the anticipated future costs to public health systems of caring for such people (personal communication with a senior official from the immigration department’s Medical Services Branch, 2021, based on data sourced from Government of Canada 2024). However, most individuals with HIV who remain in Canada are those who, by law, cannot be excluded from doing so based on their medical status. These are persons who are refugees and those who immigrate as family members.

Discovery of a Disturbing Disjuncture

An article appearing in the International Journal of STD and AIDS four years after the HIV testing policy came into effect reported on the functioning of the screening program in its first two years (Zencovich et al. 2006). The authors wrote that all refugee and immigrant persons who tested HIV positive through Canadian immigration medical screening consented to testing; received pre- and post-HIV test counselling; and, on positive diagnosis, received referrals to specialty facilities. From my career providing care and services for people with HIV, I knew that these claims were inconsistent with the material circumstances of the lives of people who test HIV positive through immigration screening; the story had to be nuanced, at best; and, furthermore, applicants to Canada have no choice but to be screened for HIV, so there is no informed consent process. Refugee and immigrant persons living with HIV and health providers among whom I worked—notably nurses, social workers, and community lawyers working pro bono with immigrants with HIV—told a different story about what the immigration process was like for people with HIV (Bisaillon 2010, 2014, 2022; Duchesneau 2004).

The dissonance between official and experiential knowledge was problematic, not least because we know that ideological accounts shape what and how people know about HIV and other diseases that are not necessarily readable on a person’s social skin (Fassin and Rechtman 2009; Treichler 1999; Young 1993; Walby 1996). Disjunctures stemming from competing forms of knowledge have been starting places for valuable anthropological scholarship focused on creating knowledge rooted in the bodily experience of people living with HIV and other serious diseases of inequality and poverty who are socially marginalized (Biehl 2005; Biehl and Moran-Thomas 2009; Farmer and Kleinman 1998; Nguyen and Peschard 2003; Scheper Hughes 1992). Academic reports such as those noted above were divorced from people’s embodied experience with immigration HIV screening; they did not reflect what was happening in people’s lives. Left unchallenged, these became the accepted representations or evidence. This disjuncture was the analytic entry point for the longer-term research project in which this chapter is set: work structured to uncover and disturb knowledge embedded in the official explanations of Canada’s mandatory HIV screening of applicants, the explicit goals of which were to establish a “scientific basis for the political strategy of grass-roots community organizing” and generate knowledge in the interests of and for immigrant and refugee people living with HIV in (or who would like to live in) Canada (G. Smith 1990, 629).4

An Approach to the Social

The analyses in this chapter emerge from an empirical study that I conducted using IE as a method of sociological inquiry (D. Smith 1990, 2006; D. Smith and Griffith 2022; see also Campbell and Manicom 1995; Luken and Vaughn 2023). I honed my abilities as an ethnographer by studying the way things were done in projects with similar ontological and epistemological commitments such as activist ethnography (Mykhalovskiy and Namaste 2019; Frampton et al. 2006; G. Smith 1990; Bresalier et al. 2002) and also the ways that medical anthropologists worked (Barrett 1996; Fassin 2005; Scheper-Hughes 1995). The approach to the social that I employ here takes organizational processes and relations of power as problematic (and fascinating) objects of study. My project joins with other institutional and political activist ethnographies that problematize organizational processes through the unmasking by thick and rich description of how ruling relations operate to produce “formal, empirically based scholarly” explications of the happenings of everyday life as understood to be relational and socially produced (Mykhalovskiy and McCoy 2002, 20). As a feminist scholar who has been deeply influenced by Dorothy Smith’s body of contributions to the social organization of knowledge and her early articulation of feminist sociology within this trajectory, I anchored my work in the standpoint of people living with HIV (D. Smith 1977, 1992). My analyses are storied and move outward from the vantage point of a woman I have called Patience, though this is not her real name, who, at the time we met, was applying for state protection as a refugee claimant from within Canada and who found out she was HIV positive in the medical examination.

Sociologist George Smith called IE a “new paradigm for sociology” because it offers both a method and a theorized way of seeing and thinking about the world that produces useable, contextualized knowledge from people’s sensual experiences with the world (1990, 630–31). In this way, I focused close and careful ethnographic attention on understanding the social organization of people’s everyday activities to be able to explicate what happens there so that awareness could be brought and changes introduced where problems were detected (Carroll 2006). Michael Orsini and Francesca Scala (2006, 115) write, “Recognition or validation of experiential knowledge can facilitate a critique of prevailing institutional norms that may be contributing to the marginalization of groups or perspectives.” For example, attention to people’s day-to-day practices led psychiatrist and anthropologist Robert Barrett (1996) to generate understandings of how the discursively and institutionally organized work practices of clinical staff (of which he was one) in an Australian psychiatric facility intersect to shape how people with schizophrenia are understood, with consequences for the health of such people. Timothy Diamond’s (1992) incisive (and deeply unsettling in the finest sense of the term) observations from his social location as a sociologist working covertly and nursing home assistant in the United States reveal insights into how the lives of staff and residents are governed by extra-local or external public and private sector interests.

Ethnographic Fieldwork

I gathered data during two phases of fieldwork and analyzed various documents and texts. The first period of fieldwork was in 2009 and 2010. I did observational work and also interviews and focus groups with thirty-three persons who were mainly living in Montréal and Toronto. I recruited people through AIDS service organizations, HIV clinics, and word of mouth.

Twenty-nine people I talked with were HIV positive, and four persons were HIV negative. I carried out interviews in English and French, with additional sessions done through interpretation in Amharic, Cantonese, Mandarin, and Mongolian. Those I spoke to hailed from twenty-four countries, and all had arrived in Canada since the mandatory HIV testing policy was introduced. Most people were refugee applicants at various stages in their immigration application process. My talk with people was conceptually organized by what I came to call their “immigration application work” (Bisaillon 2020, 2022).

In a second phase of fieldwork, I gathered data in twenty-eight bilingual interviews in Toronto, Montréal, Ottawa, and Gatineau from 2010 to 2011. Interviewees included people in occupational roles identified by people with HIV as important to their immigration application process. These included lawyers, immigration doctors, HIV physicians, social workers, nurses, AIDS service organization caseworkers, shelter and Public Health personnel, Canadian Border Services Agency employees, and government advisors and officials. I recruited people directly. In both phases, my priority was on attracting people who would offer a broad selection of personal and professional experiences with processes associated with the mandatory HIV testing policy and immigration medical examination.

During both phases of fieldwork, I reviewed official documents, people’s own immigration-related paperwork, legislation, forms, websites, and other publicly available texts such as Canada’s Immigration and Refugee Protection Act (S.C. 2001, c. 27) and Immigration and Refugee Protection Regulations (SOR/2002–227); Canada’s mandatory HIV testing policy (CIC 2002); Handbook for Designated Medical Practitioners (Minister of Public Works and Government Services Canada 2009 [also editions from 1992, 2003]; hereafter referred to as Handbook); and the “Personal Identification Form” (changed to the “Basis of Claim Form” in 2012) that people who are applying as refugees fill out. For this study, I received ethics approvals and respected standards in Canada’s Tri-Council Policy Statement on research practice.

Findings: Everyday Work and Textual Practices

That people with HIV who apply for Canadian permanent residency do a lot of work to immigrate to Canada is a gross understatement. The root of this is the firm desire to become a Canadian citizen, which they see as a privilege and an opportunity. Applicants acquiesce to all that is required of them with the idea of becoming Canadians, including submitting to whatever health screening is asked of them. There is, however, a disjuncture: notions of privilege are not part of the everyday experience of people I met with. That experience is, rather, a matter of waiting (and waiting some more), wondering, hoping, and coping with their HIV diagnosis. What this looks and feels like is broached below. My descriptions and analyses emerge from within the activities stemming from the Canadian immigration medical examination, and I centre these within the experiences of Patience. She and I first met at a women’s sexual health organization where I was working at the time.

“Urgent: Contact the Doctor Immediately”

Patience, a doctor in her country, described her earliest days in Canada to me, during which she lived in a shelter for several months. She said that a memorable feature about the place was that it was while she lived there that she learned that she was living with HIV.

At the Canadian border, Patience was instructed to see a government-appointed immigration doctor. She left the border with an information package, which included a list of state-affiliated doctors. Promptly, Patience reported to one of the doctors on this list, choosing the one closest to the shelter. He did a brief examination of her body, and his nurse drew her blood. The doctor told her that if there were problems, someone from his office would contact her.

Ten days later, a note bearing her name and a handwritten inscription appeared on the communal bulletin board of the shelter. It read “PATIENCE. URGENT : CONTACTER LE MÉDECIN TOUT DE SUITE.” She quickly removed the note. Since arriving in the shelter, Patience learned that the general chatter among residents, all people recently arrived in Canada from developing world societies, was that if a person received a call back from the immigration doctor’s office, this signalled HIV. Patience’s heart sank. The announcement made her feel fearful and bare.

Patience talked to me about her second visit to the doctor. She was distressed by the brevity of the encounter—how little she and he spoke after her diagnosis. Patience had a good deal of expectation and knowledge about what the visit could have involved given that she, too, was a medical doctor. She walked away from the medical office with a slip of paper with the name and address of a clinic treating people living with HIV. Patience was told to report to that hospital, and later that day, she took the bus there.

“Of Course They Took Blood for HIV”

The immigration medical examination is one of the first steps that people applying for permanent residency are asked to do. People I met with place considerable importance on this examination in part because they come to realize that the Canadian government likewise places a lot of importance on it. Applicants want to “pass” the medical examination and be screened forward through the immigration process. Patience told me about how she came to know about the medical examination and what she did to prepare for it, saying,

At the YMCA [shelter], they gave us an information package that contained the steps we had to go through to complete steps to immigrate—for example, go to the medical visit, take the immigration course, go to the refugee-receiving centre, and fill out the Personal Information Form. With that piece of paper, you check off the list. In that way, you know what you must do, and you know what you have done. You know how much time you must spend on each activity.

Describing her first visit to the immigration doctor, Patience said,

You just had to fill in the normal paperwork, answering such questions as, “Has anyone in your family had HIV or AIDS? Have you ever had HIV?” At that time, of course, I knew [assumed] I was clean. Negative.
I was very sure of myself because I had had my last HIV test one year prior to that. I knew [thought] I wasn’t sick. I did the HIV test and lots of other medical tests, including X-rays. Of course, they took blood for HIV. Immigration did not tell me they were doing an HIV test.

As we see here, Patience had not been told, in the context of the immigration process, that she was being tested for HIV. When I asked an immigration doctor about this, he said,

You are supposed to advise patients, “We are doing these tests, and we are doing an HIV screen.” You do a bit of a screen to see if that is a concern beforehand—so that they are aware of why we are testing. If it is [HIV] positive, we will call them in. There is supposed to be pre- and post-test counselling [for HIV]. I suppose you could call it a pre-test “notification.”

The immigration doctor’s statement brings attention to several intriguing points. The parameters for what this doctoring function “is supposed to” consist of and the institutional logic for how this work is carried out are outlined in the official Handbook and periodic operational updates, which are issued by the immigration department. Physicians can run diagnostic tests for conditions above and beyond the obligatory trio of HIV, syphilis, and hepatitis, but these are not part of the routine tests, as the immigration doctor reveals.

My review of the forms and instructions in the 2009 Handbook shows that the Canadian government places importance on the delivery of “pre- and post-test counselling,” since specific forms and instructions were additions from the previous edition of the Handbook. Through these publications, we can read that the cost doctors can invoice the immigration department for delivering post-test counselling is more than the cost of the medical examination itself.

In the immigration doctor’s statement above, he explains that the “notification” is how people may be advised that HIV antibodies will be searched for in their blood sample. The applicant does not give consent to an HIV test because the person has no choice but to be tested. Of relevant note here is that the mandatory HIV testing of Canadian permanent residents and citizens is unlawful except under very rare circumstances (Klein 2001). Thus, a practice that Canadians would only very exceptionally experience is done routinely to prospective immigrants.

“I Began Asking Questions of Him, and He Became Friendlier”

In response to the note tacked on her shelter’s bulletin board, Patience called the doctor’s office as she was asked. A nurse answered, who said, “There is something wrong with your medicals. We need to see you again.” Patience pressed to know more. “When you come here, it is quite confidential; we will let you know,” the nurse replied. This is the moment when the trajectory of an applicant living with HIV departs sharply from that of an applicant who is HIV negative.

A week went by, experienced anxiously for Patience, before she went back to see the immigration physician for a second visit. “I sat there with the doctor,” she said. “We were the only ones in the room. He said, ‘I have some bad news for you. Did you know that you were HIV positive?’” She did not. Her mind raced and she wondered, “What will the doctor do with the results? Who will know? Will it be possible for me to stay in Canada? Where will he send the record of my HIV-positive diagnosis?”

Patience did not say a word. She sat still and focused on not making a sound. This absence of talk is analytically interesting for how it draws our attention to strategies that people I spoke with practice decidedly: they set forth to engage with physicians on their terms. People’s dialogical practices, as they sit and do the mental work of figuring out how they might shape the medical visit in particular ways, take several forms, including talking when prompted, asking few questions, offering deliberate silence, and responding to questions with short answers. One person told me about how he used both deliberative talk and silence moments after being told that he was HIV positive:

The first question was, “Do you have sex with men?” [The immigration doctor] asked me if I was having sex with men in Canada. I said [to myself], “Oh my God! He is inquiring to see if I am spreading this in Canada.” When he asked me the question about my behaviour, whether I have sex with men, his indirect manner of coming to the point of me being HIV positive, I knew, without a doubt, that I was HIV positive. After that, I began asking questions of him, and he became friendlier. I began asking him about things in Canada. I said to him, “So, what next?”

When I discussed this issue of people’s silent response to their diagnosis, immigration doctors I met talked to me about being puzzled. They arrive at asking themselves whether the person sitting in front of them already knew their HIV status. “There is a good number [of people] who are diagnosed at the moment of immigration. Sometimes I wonder if they knew before and just do not say so at their entrance to Canada,” said an immigration doctor. However, people’s directed talk and deliberative silence are meaningful and not mysterious when we see the absence of talk as shaped by the ruling relations organizing the immigration medical visit, including the interests tied up in the doctors’ work and the stakes and lived implications for people with HIV of receiving a problematic bill of health.

“We Are the Guys in the Trenches”

In conversation and after conversation with the immigration doctors I met, they emphasize that they are not decision-makers. “I am a fact finder—gathering information, giving it to a higher level that has a protocol to make a decision. We are the guys in the trenches,” said one physician. Nevertheless, the immigration doctors’ function must be unpacked: in this role, such contract physicians are critical actors in the immigration system and indeed the lives of people who apply to reside in Canada permanently. Doctors are charged with detecting specific blood and lung conditions, and perhaps other maladies at their discretion, and reporting these in a medical file to the government. On receiving doctors’ reports, medical officers employed within the immigration department bureaucracy proceed to anticipate how much the applicant persons are forecasted to cost public health care and services. Thus, the way immigration doctoring is organized institutionally is entirely focused on the discovery and disclosure of medical conditions that will render applicants inadmissible to immigrate to Canada.

One doctor said the following to me: “My work is with immigration—with Ottawa, the federal government, principally.” Applicants living with HIV do not initially realize that the immigration doctors drawing their blood are working in state interests rather than their subjective interests. The relationship between themselves and immigration doctors is not a therapeutic one in this institutional instance. The moment that some people with HIV told me they realized the reality of the doctors’ job purpose was when they were told of their HIV status. At this point, they may receive a referral to an HIV specialist, with whom they are required by the immigration department to follow up. People told me that they felt confused, conflicted, and tense during the immigration medical examination process, which commonly consists of a first and repeat visit to the same doctor. Here again, that people feel anxious and ill at ease in these situations is not bewildering when we understand such feelings as responses to the social organization of the immigration doctors’ work within relations of medical- and health-based exclusion.

Immigration doctors in Montréal and Toronto have developed referral systems and are professionally well connected to services and facilities that specialize in care for people living with HIV. When a person tests positive, doctors generally provide the person with the name and address of an HIV clinic or specialized unit within a hospital. In an everyday way, then, post-test care in Canada is shifted to specialist doctors and to people working within the HIV and sexual health milieus. In conversation with a lawyer whose legal aid practice is almost entirely devoted to working with people with HIV who are refugee claimants and immigrants, he told me about writing a letter to the immigration department asking for direct guidance about where and with whom the responsibility for delivering HIV test counselling before and after a diagnosis lies. He was concerned about this because his clients generally did not receive this care from the immigration doctor. Some months later, he received a response (Binette 2009), which read,

Based on these provisions [on post-test counselling in the 2003 Handbook], it is clearly the DMP’s [designated medical practitioner’s] duty to provide HIV post-test counselling to all HIV positive applicants and to sign the Post-Test Counselling form . . . the form should be signed by the immigration doctor. . . . We will also create a reminder to all immigration doctors on our website on this subject.

As I came to learn, immigration doctors’ communication with the immigration department is irregular and infrequent. “We have a protocol. If you do your work, you will not hear from [the immigration department]. I have very limited communication with CIC [Citizenship and Immigration Canada]. We do our job, and that is it,” said one doctor. The purposefulness and effectiveness of transmitting the message above to doctors via the department’s website is thus questionable.

“I Eased His Job, or Maybe I Made It More Difficult”

Patience talked to me about her second visit to the immigration doctor and what happened after she found out that she was living with HIV:

He gave me a piece of paper that I had to sign that stated that I acknowledged that I was tested HIV positive, that I am aware that I am HIV positive, and that I had been educated about the means of transmission. I had not been educated through this doctor. Probably he was going to give me that talk. I read through his paper and agreed with everything it said. It said, “You cannot donate blood, protect yourself when engaging in sex, cannot give organs.” That was the attempt at counselling. I eased his job, or maybe I made it more difficult

Patience’s statement points to an interface between embodied experience and institutional processes when a “piece of paper” enters her experience. In outlining details of the HIV testing program prior to its implementation in 2002, the then minister of immigration, Elinor Caplan, stated that counselling for HIV would be a part of the service delivered to applicants, as per Canadian and international guidelines at the time (Klein 2001). The “Acknowledgement of HIV Post-test Counselling” form to which Patience referred is a standardized, one-page government document bearing a four-line text written in the first person. In signing, the person agrees to have received counselling “on several topics” related to the “HIV-positive condition.”

When someone receives this acknowledgement form, they have just received a diagnosis of HIV. Whether or not this is a first diagnosis (perhaps the person has tested HIV positive in other circumstances), all applicants living with HIV describe the diagnosis as instilling fear, loss, and worry—concerns about bodily survival. Someone shared his candid thoughts with me about being diagnosed through the immigration screening process: “I kind of expected the results. I think that every gay man expects, or is ready, or assumes you can get it. It was still really, really hard. It is so shocking.” About this acknowledgement form, a doctor I spoke with said,

Immigration Canada asks us to fill out a form called “Acknowledgement of HIV Post-test Counselling” form. This is in the Handbook. This is to acknowledge that people have been counselled. I sign, and the client also has to sign. It is mandatory for us to do counselling. It is mandatory to submit this signed form to Immigration when we submit the [medical] file; the client acknowledges having received counselling.

However, there is a sharp and stark contradiction between the embodied accounts of people with HIV with this acknowledgement form and how immigration doctors use it, what the government does with it, and what the latter claims happens in relation to it. The form does not appear to be routinely integrated into what doctors do with applicants living with HIV; few of the latter reported knowing about or putting their signature to this document. At the same time, the government frames the form as an important administrative and accountability tool. In the 2009 Handbook, this form was included “to at least have a control record that they were actually receiving post-counselling,” said a government advisor from the immigration department’s Medical Services Branch with whom I discussed this issue. As part of their review work associated with medical files of HIV-positive applicants, immigration department medical officers are said to ensure that this acknowledgement form is included in the doctor’s submission. Regrettably, I cannot confirm this because I did not have sustained access to the federal immigration department work site.

What I heard from people with HIV revealed to me that immigration doctors do not do the work of educating and counselling very well. For applicants to Canada, the immigration doctor is the first face that they associate with Canadian health care and service delivery. Their two visits to see the doctor are at odds with what people expect from a medical examination by a Canadian or by a person affiliated with the Canadian government. People are disappointed that they are not cared for in certain ways and surprised that the medical visits are short, that dialogue is limited, and that messages emphasize population-level health issues rather than concerns related to their personal well-being. On the immigration department’s website, applicants locate a doctor’s name, contact details, and the languages the person speaks—choosing a doctor who speaks either their mother tongue or a language they speak well and whose office is close to where they live. A native Spanish speaker spoke to me about the reasons he chose the doctor he did:

The immigration office gave me a paper for the medical exam. They gave me a list of the number[s] for the doctors. The list explains about who’s the doctor, what language he speaks. One doctor said, “Spanish and Portuguese,” so I chose this doctor. When I went to the doctor, he didn’t speak Spanish. He spoke Portuguese. I said, “What happened?” and he tells me, “It’s the same language.” But it was not the same. I didn’t understand what he was doing. He explained everything, but it was in Portuguese. Maybe I understood 40 percent, but it was not enough.

“If You Are Starting Off, It Is Likely an Important Tool”

While the immigration department has researched, updated, and produced an official handbook and availed doctors of successive editions of the latter over time, doctors reported to me that they did not make use of this particular guidebook in their immigration medicine work. Rather, what they do is activate their common-sense working knowledge in dealing with people they diagnose with HIV. About this Handbook, a doctor I talked with said, “If you are starting off, it is likely an important tool. It encompasses everything [an immigration doctor] should know about his job. Because I have been doing this for so long, there is not much that is enlightening.”

Within this doctor’s statement, another feature shaping the immigration medical visit comes to light: the physician’s formal education and current knowledge about HIV. Immigration doctors based in Canada are most often general practitioners, and they generally have had four years of medical training and three years of residency. Their training may or may not have equipped them with the skills of caring for people diagnosed with HIV. An HIV specialist I interviewed commented that his immigration doctor colleagues were generally around or above retirement age, a point that directs attention to the timeline of the epidemic that manifested in bodies during the mid- to late 1980s in North America; HIV education would not have been part of the formal medical education of Canadian immigration doctors of a certain age. It would be unreasonable for me to suggest that immigration doctors, who are general practitioners, should be specialists in providing care for those with HIV. However, since Canada, for the time being, obliges applicants to submit to HIV testing, I contend that it is definitely reasonable to expect that physicians should communicate information about HIV and AIDS and should explore positive results both prior to testing and after positive results are disclosed.

Conclusion

Centring my analysis in what I learned from interactions with Patience and other applicants for Canadian permanent residency living with HIV, and then with professional practitioners and bureaucrats whose work (and bank accounts) tethers them to the immigration medical program, through this chapter, I have explored the social organization of routine processes associated with Canada’s mandatory HIV testing policy and scratched beneath the surface of official interpretations of what goes on through the medical examination for people with HIV. The Handbook is a text in which the immigration department references its “standards” that are said to govern the medical examination and doctoring practices (CIC 2010, 6). In a presentation to the Association québécoise des avocats et avocates en droit de l’immigration, “providing appropriate counselling” was listed as one of the “five duties” of immigration doctors (CIC 2010, 6). Public education and the public availability of the Handbook promote the notion, which turns out to be an ideological one, that certain professional practices are happening during the medical examination—despite empirical reports showing that counselling, for example, is an exception rather than a rule. The idea that immigration doctors are informed about counselling conventions is also reinforced through this work. As I have demonstrated, however, this is a staunchly ideological position, which supports the position that the state has at times cultivated about itself publicly: Canada as a country that receives persons in need of protection because it is motivated by a long-standing “humanitarian tradition” that rewards “legitimate refugees” with a “safe haven” (CIC 2011).

The immigration medical examination as it currently functions is socially organized inside of state interests and outside of an applicant’s subjective interests. That there generally is no pre- and post-testing counselling after an HIV-positive diagnosis is not mysterious when the social relations embedded within the medical examination are investigated. I would like for these generally unknown features of the social organization of the Canadian immigration medical program and HIV testing within this program to be widely and broadly known to all people in Canada and to all people who would like to settle in Canada permanently. To persons working in medical, legal, and bureaucratic roles associated with upholding these practices, I would like for them to read this chapter and understand the social organization of their thinking and practices and the attendant implications for people living with HIV on whom or on behalf of whom they do what they do. I have shown how difficulties experienced by applicants are produced because of how things are organized institutionally through professional and bureaucratic work practices.

In reading this chapter, those working with or on behalf of immigrant and refugee applicants with HIV might take the analyses proffered as starting points for doing an institutional “audit” of the structural conditions organizing their work environments (Pence 2001, 226). In the interests of the people with or for whom we work, those inclined toward activism—such as my lawyer colleague who wrote a letter to the immigration department to get to the bottom of who was in charge of delivering care and service to applicants with HIV while querying why these services were not happening at all times everywhere—can, in opening their daily worlds to institutional ethnographic scrutiny, produce empirical evidence to support claims-making about the need for structural change at specific rather than general places. In making problems and lacunae visible through the challenging (and rewarding) effort of explaining how and where problems are organized in the practices of doctors, lawyers, and bureaucrats, I hope that those who oversee the immigration medical program and uphold HIV-related practices will hear the call and follow the evidence for how and where to change the immigration medical system so that harms carried out through it can, once and for all, be dispensed of.

References

Barrett, Robert. 1996. The Psychiatric Team and the Social Definition of Schizophrenia: An Anthropological Study of Person and Illness. Cambridge: Cambridge University Press.
Biehl, João. 2005. “Technologies of Invisibility.” In Anthropologies of Modernity: Foucault, Governmentality, and Life Politics, edited by John Xavier Inda, 248–71. West Sussex: Blackwell.
Biehl, João, and Amy Moran-Thomas. 2009. “Symptom: Subjectivities, Social Ills, Technologies.” Annual Review of Anthropology 38:267–88.
Binette, N. 2009. “HIV Post-test Counselling.” Personal communication in response to David Thompson’s request for information about official procedures relating to HIV post-test counselling for HIV. On file with author.
Bisaillon, Laura. 2010. “Human Rights Consequences of Mandatory HIV Screening Policy of Newcomers to Canada.” Health and Human Rights: International Journal 12(2): 119–34.
Bisaillon, Laura. 2013. “Contradictions and Dilemmas within the Practice of Immigration Medicine.” Canadian Journal of Public Health 104(1): e45–e51.
Bisaillon, Laura. 2014. “Introduction: The Politics of Practice and the Contradictions for People, Policy and Providing Care: Investigations into the Implications of Health Work Organized within State Interests.” Public Health Ethics 7(3): 225–28.
Bisaillon, Laura, dir. 2020. The Unmaking of Medical Inadmissibility. Toronto: Inadmissibles Art Collective.
Bisaillon, Laura. 2022. Screening Out: HIV Testing and the Canadian Immigration Experience. Vancouver: University of British Columbia Press.
Bresalier, Michael, Loralee Gillis, Craig McClure, Liza McCoy, Eric Mykhalovskiy, Darien Taylor, and Michelle Webber. 2002. Making Care Visible: Antiretroviral Therapy and the Health Work of People Living with HIV/AIDS. Toronto: Making Care Visible Working Group.
Campbell, Marie, and Ann Manicom, eds. 1995. Knowledge, Experience, and Ruling Relations: Studies in the Social Organization of Knowledge. Toronto: University of Toronto Press.
Canadian HIV/AIDS Legal Network. 2009. Canada’s Immigration Policy as It Affects People Living with HIV/AIDS. Toronto: Canadian HIV/AIDS Legal Network. http://www.aidslaw.ca/publications/interfaces/downloadFile.php?ref=1477.
Carroll, William. 2006. “Marx’s Method and the Contributions of Institutional Ethnography.” In Sociology for Changing the World: Social Movements / Social Research, edited by Caelie Frampton, Gary Kinsman, Andrew K. Thompson, and Kate Tilleczek, 232–45. Black Point, NS: Fernwood.
CIC (Citizenship and Immigration Canada). 2002. Operational Processing Instruction 2002–2004. Medical Assessment of HIV Positive Applicants. Ottawa: CIC.
CIC. 2010. “Immigration Medical Assessment and Inadmissibility Under Health Grounds.” Presentation to the Association québécoise des avocats et avocates en droit de l’immigration, Montréal, 2010; on file with author.
CIC. 2011. “Canada Welcomes Highest Number of Legal Immigrants in 50 Years While Taking Action to Maintain the Integrity of Canada’s Immigration System.” Marketwire, 2011. http://www.marketwire.com/press-release/Canada-Welcomes-Highest-Number-Legal-Immigrants-50-Years-While-Taking-Action-Maintain-1394803.htm.
CIC. 2021. “Departmental Results Framework.” Immigration and Refugee Board of Canada, accessed November 23, 2021. https://www.irb-cisr.gc.ca/en/reports-publications/planning-performance/Pages/departmental-results-report-2021-r.aspx.
Diamond, Tim. 1992. Making Gray Gold: Narratives of Nursing Home Care. Chicago: University of Chicago Press.
Duchesneau, Claire. 2004. “Lessons Learned in Working with HIV/AIDS African Refugees and Illegal Immigrants in an Out-Patient Hospital Setting.” Intervention 120:47–53.
Farmer, Paul, and Arthur Kleinman. 1998. “AIDS and Human Suffering.” In Understanding and Applying Medical Anthropology, edited by Peter Brown, 333–42. Mountain View, CA: Mayfield.
Fassin, Didier. 2005. “Le sens de la santé. Anthropologie des politiques de la vie.” In Anthropologie médicale: Ancrages locaux, défis globaux, edited by Francine Saillant and Serge Genest, 283–389. Québec: Presses de l’Université Laval.
Fassin, Didier, and Richard Rechtman. 2009. The Empire of Trauma: An Inquiry into the Condition of Victimhood. Princeton, NJ: Princeton University Press.
Frampton, Caelie, Gary Kinsman, Andrew K. Thompson, and Kate Tilleczek, eds. 2006. Sociology for Changing the World: Social Movements / Social Research. Black Point, NS: Fernwood.
Goldstein, Diane. 2004. Once Upon a Virus: AIDS Legends and Vernacular Risk Perception. Logan: Utah State University.
Government of Canada. 2024. “Departmental Results Reports.” Last modified February 2, 2024. https://www.canada.ca/en/immigration-refugees-citizenship/corporate/publications-manuals/departmental-performance-reports.html.
Imrie, Caitlin. 2019. “Canada’s Approach to Managed Migration: Migration Health.” International Metropolis Conference, Gatineau, June 24, 2019. https://www.canada.ca/en/immigration-refugees-citizenship/services/metropolis-final-report.html.
Klein, Alana. 2001. HIV/AIDS and Immigration: Final Report. Toronto: Canadian HIV/AIDS Legal Network. http://www.aidslaw.ca/publications/publicationsdocEN.php?ref=103.
Langer, Lawrence. 1991. Holocaust Testimonies: The Ruins of Memory. New Haven, CT: Yale University Press.
Luken, Paul, and Suzanne Vaughan. 2023. Critical Commentary on Institutional Ethnography: IE Scholars Speak to Its Promise. London: Palgrave MacMillan.
Minister of Public Works and Government Services Canada. 2009. Handbook for Designated Medical Practitioners. N.p.: Minister of Public Works and Government Services Canada. http://www.cic.gc.ca/English/pdf/pub/dmp-handbook2009.pdf.
Mykhalovskiy, Eric, and Liza McCoy. 2002. “Troubling Ruling Discourses of Health: Using Institutional Ethnography in Community-Based Research.” Critical Public Health 12(1): 17–37.
Mykhalovskiy, Eric, and Viviane Namaste, 2019. Thinking Differently About HIV/AIDS: Contributions from Critical Social Science. Vancouver: University of British Columbia Press.
Nguyen, Vinh-Kim, and Karine Peschard. 2003. “Anthropology, Inequality, and Disease: A Review.” Annual Review of Anthropology 32:447–74.
Orsini, Michael, and Francesca Scala. 2006. “‘Every Virus Tells a Story’: Toward a Narrative-Centred Approach to Health Policy.” Policy and Society 25(2): 125–50.
Pence, Ellen. 2001. “Safety for Battered Women in a Textually Mediated Legal System.” Studies in Cultures, Organizations and Societies 7(2): 199–229.
Scheper-Hughes, Nancy. 1992. Death Without Weeping: The Violence of Everyday Life in Brazil. Berkeley: University of California Press.
Scheper-Hughes, Nancy. 1995. “The Primacy of the Ethical: Propositions for a Militant Anthropology.” Current Anthropology 36(3): 409–40.
Smith, Dorothy E. 1977. Feminism and Marxism: A Place to Begin. A Way to Go. Vancouver: New Star Books.
Smith, Dorothy E. 1990. The Conceptual Practices of Power: A Feminist Sociology of Knowledge. Toronto: University of Toronto Press.
Smith, Dorothy E. 1992. “Sociology from Women’s Experience: A Reaffirmation.” Sociological Theory 10(1): 88–98.
Smith, Dorothy E., ed. 2006. Institutional Ethnography as Practice. Oxford: Rowman & Littlefield.
Smith, Dorothy E., and Alison Griffith. 2022. Simply Institutional Ethnography: Creating a Sociology for People. Toronto: University of Toronto Press.
Smith, George W. 1990. “Political Activist as Ethnographer.” Social Problems 37(4): 629–48.
Treichler, Paula. 1999. How to Have a Theory in an Epidemic: Cultural Chronicles of AIDS. Durham, NC: Duke University Press.
Walby, Catherine. 1996. AIDS and the Body Politic: Biomedicine and Sexual Difference. London: Routledge.
Yanow, Dvora. 2000. Conducting Interpretive Policy Analysis. Thousand Oaks: Sage.
Young, Allan. 1993. “A Description of How Ideology Shapes Knowledge of a Mental Disorder (Post-traumatic Stress Disorder).” In Knowledge, Power, and Practice: The Anthropology of Medicine and Everyday Life, edited by Shirley Lindenbaum and Margaret Lock, 108–28. Berkeley: University of California Press.
Zencovich, Militza, Kerry Kennedy, Douglas MacPherson, and Brian Gushulak. 2006. “Immigration Medical Screening and HIV Infection in Canada.” International Journal of STD and AIDS 17:813–16.

1 Goldstein (2004, xiii).

2 Jean Améry in Langer (1991, 89).

3 For this chapter, I was awarded the 2011 George W. Smith Outstanding Graduate Student Paper Award by the Institutional Ethnography Division of the Society for the Study of Social Problems. Later that year, this piece appeared, titled as here, in Aporia: The Nursing Journal 3(4): 5–14. As I prepared this chapter for this volume, since time had passed since its initial publication, I updated its supporting empirical data and made editorial adjustments.

4 I published my long-term ethnography as Screening Out: HIV Testing and the Canadian Immigration Experience (Vancouver: University of British Columbia Press, 2022). Based on this research, I made the film The Unmaking of Medical Inadmissibility (Toronto: Inadmissibles Art Collective, 2020), https://vimeo.com/448054053.

Part 3. Frontline Research and the Ethics of Engagement